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BACKGROUND:Over the past decades, increased knowledge about childhood abuse and trauma have prompted changes in child welfare policy, and practice that may have affected the out-of-home (OOH) care population. However, little is known about recent national trends in child maltreatment, OOH placement, or characteristics of children in OOH care. The objective of this study was to examine trends in child maltreatment and characteristics of children in OOH care.METHODS:We analyzed 2 federal administrative databases to identify and characterize US children who were maltreated (National Child Abuse and Neglect Data System) or in OOH care (Adoption and Foster Care Analysis and Reporting System). We assessed trends between 2000 and 2010.RESULTS:The number of suspected maltreatment cases increased 17% from 2000 to 2010, yet the number of substantiated cases decreased 7% and the number of children in OOH care decreased 25%. Despite the decrease in OOH placements, we found a 19% increase in the number of children who entered OOH care because of maltreatment (vs other causes), a 36% increase in the number of children with multiple (vs single) types of maltreatment, and a 60% increase in the number of children in OOH care identified as emotionally disturbed.CONCLUSIONS:From 2000 to 2010, fewer suspected cases of maltreatment were substantiated, despite increased investigations, and fewer maltreated children were placed in OOH care. These changes may have led to a smaller but more complex OOH care population with substantial previous trauma and emotional problems.

Children and adolescents involved with child welfare, especially those who are removed from their family of origin and placed in out-of-home care, often present with complex and serious physical, mental health, developmental, and psychosocial problems rooted in childhood adversity and trauma. As such, they are designated as children with special health care needs. There are many barriers to providing high-quality comprehensive health care services to children and adolescents whose lives are characterized by transience and uncertainty. 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 in the context of a medical home, and health care coordination and advocacy on their behalf. This technical report supports the policy statement of the same title.

1. Moira Szilagyi, MD, PhD* 1. 2. *Medical Director, Foster Care Pediatrics, Monroe County Health Department, Rochester, NY. 1. The primary reasons cited for placement in foster care (>80% of admissions of younger children) are child abuse and neglect. 2. Children in foster care are at high risk for human immunodeficiency virus (HIV) infection related to maternal lifestyle. 3. Biological parents retain guardianship while their children are in foster care unless parental rights are terminated. 4. Behavioral problems of children in foster care escalate with stress brought about, for example, by changes in visitation patterns, changes in foster care placement, and termination of parental rights. 5. Transracial adoption will become more common in foster care with the enactment of recent legislation that is intended to address the needs of the large number of minority children awaiting adoption. The new legislation prohibits the use of race as the sole criterion for adoptive placement, although it still may be one of several criteria considered. 6. Children in foster care have higher rates of chronic medical illness, mental health problems, behavioral disorders, developmental delays, and educational disabilities than other poor children. 7. The primary unmet health care need of children in foster care is mental health evaluation and treatment. About 500,000 children reside in foster care on any given day in the United States. They are primarily the children of the indigent, and their lives prior to placement were riddled by violence and neglect. Removed from or abandoned by their families, these children were placed into a system intended to nurture and repair them, while facilitating the rehabilitation of their families. In reality, foster care has become a system of last resort for the most vulnerable children and intransigent families. Foster care is intended to be a temporary respite for a family in crisis, with the ultimate goal being reunification of the child and family. However, this system is in crisis, crushed by huge caseloads, families who have …

1. Moira Szilagyi, MD, PhD* 1. *Starlight Pediatrics, Rochester, NY. In September 2010, 408,425 children and adolescents resided in foster care. Recent legislation highlights an increasing focus on involving pediatricians in supporting children in foster care and defines specific requirements relevant to the role of pediatricians. After completing this article, readers should be able to: 1. Understand the purposes of foster care and the problems associated with pre-placement childhood trauma and foster care placement. 2. Know the basics of how foster care systems work. 3. Recognize that children in foster care are by definition children with special health-care needs. 4. Understand that many children in foster care have behavioral problems that can lead to placement instability that, in turn, can exacerbate those problems. 5. Understand the physician’s role in foster care. Foster care is intended to provide a temporary haven for children during a time of family crisis when children are at imminent risk for harm. The goals of foster care are to promote child health, safety, permanency, and well-being. Foster care also has the mission of building on family strengths and providing birth parents with the services they need to reconnect (reunify) with their children. Because children fare best in stable and nurturing families, there has been an increased emphasis in the past decade on shortening the time to permanency through reunification, placement with relatives, and adoption. Foster care also has the obligation to prepare youth for independent living when none of these permanency options is possible. In some states, more than one third of children in foster care are in court-ordered (formal) kinship placements, arrangements in which the related (kin) caregiver may or may not be a certified foster parent. Even outside the child welfare …

Little is known about how best to implement behavioral screening recommendations in practice, especially for children in foster care, who are at risk for having social-emotional problems. Two validated screening tools are recommended for use with young children: the Ages and Stages Questionnaire: Social Emotional (ASQ-SE) identifies emotional problems, and the Ages and Stages Questionnaire (ASQ) identifies general developmental delays in five domains, including personal-social problems. The current study examined: (1) whether systematic use of a social-emotional screening tool improves the detection rate of social-emotional problems, compared to reliance on clinical judgment; (2) the relative effectiveness of two validated instruments to screen for social-emotional problems; and (3) the patterns of social-emotional problems among children in foster care.We used retrospective chart review of children in foster care ages 6 months to 5.5 years: 192 children before and 159 after screening implementation, to measure detection rates for social-emotional problems among children. The ASQ-SE and the ASQ were used in multivariable logistic regression analyses to examine associations between children with social-emotional problems.Use of the screening tool identified 24% of the children as having a social-emotional problem, while provider surveillance detected 4%. We identified significantly more children with social-emotional problems using the ASQ-SE than using the ASQ, and agreement between the instruments ranged from 56% to 75%, when data were stratified by age group. Multivariable modeling showed that preschool children were more likely to have a social-emotional problem than toddlers and infants (aOR = 3.4, 95% CI = 1.1-10.8).Systematic screening using the ASQ-SE increased the detection rate for social-emotional problems among young children in foster care, compared to provider surveillance and the ASQ. A specific social-emotional screening tool appears to detect children with psychosocial concerns who would not be detected with a broader developmental screening tool.

OBJECTIVE:Our goal was to determine if systematic use of a validated developmental screening instrument is feasible and improves the detection of developmental delay (DD) in a pediatric medical home for children in foster care.DESIGN AND METHODS:This study had a pre-post study design, following a practice intervention to screen all children in foster care for DD by using the Ages and Stages Questionnaire (ASQ). The baseline detection rate was determined by medical chart review for all children aged 4 to 61 months who were new to foster care (NFC) during a 2-year period. After implementation of systematic screening, caregivers of young children who were NFC or already in foster care (IFC) completed the ASQ at preventive health care visits. We assessed the feasibility of systematic screening (the percentage of ASQs completed among the NFC and IFC groups). We compared the detection of DD among the baseline NFC group and the screening-NFC group by using bivariate and multivariable logistic regression.RESULTS:Of 261 visits that occurred after initiation of screening, 251 (96%) visits had a completed ASQ form in the medical chart, demonstrating high feasibility. Among children who were NFC, the detection of DD was higher in the screening than baseline period for the entire population (58% vs 29%; P < .001), for each age group (infants: 37% vs 14%; toddlers: 89% vs 42%; preschool: 82% vs 44%; all P ≤ .01), and for all developmental domains. On adjusted analyses, the detection of potential DD in toddler and preschool children was higher among the NFC screening group than the NFC baseline group.CONCLUSION:Systematic screening for DD using the ASQ was feasible and seemed to double the detection of DDs.

PURPOSE OF REVIEW This study highlights recent publications on foster care, focusing on concerns for the general pediatrician, including risk factors for foster care placement, outcomes of foster care, healthcare and screening standards, and developmental and mental health problems. RECENT FINDINGS Many children and youth in foster care have been exposed to complex trauma prior to foster care placement. As clinicians gain a greater understanding of the life experiences of children in foster care, more preventive and supportive efforts can be implemented in the clinical setting, specifically around health and mental health issues. Enhanced awareness of the issues would enable healthcare professionals to advocate effectively for the needs of children in the child welfare system. To address the complex health and socio-emotional needs of children in foster care, several healthcare models and innovative programs for the care of children in foster care have been developed. This literature review for the past year suggests a lack in program evaluation of these efforts. SUMMARY Pediatricians have the opportunity to address physical and mental health issues for children in foster care, and can provide anticipatory guidance to foster and biological parents who bring their children for evaluation.

The population of children in foster care is rapidly growing. Previous local and state-level analyses have measured the prevalence of chronic conditions among such children to be from 44%-82%. The study objective was to identify factors associated with chronic conditions among a nationally representative sample of children in foster care for one year. The authors analyzed data from The National Survey of Child and Adolescent Well-Being (NSCAW), Wave 1, the first national dataset of children in the child welfare system. In regression analysis, factors significantly associated with having a chronic condition included: child age under 2 years, caregiver race/ethnicity other than Hispanic, and relatively few household members. Discussion includes consideration of chronic conditions in this high-risk population.

SOMETIMES AMOMENT can alter your life. For me, one such moment came in the middle of residency. I was moonlighting at the local health department—as residency obligations permitted—just 2 hours a week, seeing children and teens in foster care for their “annual exam.” The clinic provided basic care for about 200 of the 1200 children and teens in foster care in our county. Back then, the clinic operated very differently. Every patient got a 9 AM appointment time and was given a number by which they were called back for what amounted to a brief physical. The nurses took the histories. I spent my first few weeks there working on some changes—providing individual appointment times, using names instead of numbers, and obtaining health histories myself. Each time I went, I was greeted by Eleanor, a veteran nurse who often said to me, “These children deserve better.” But it wasn’t until I met 16-year-old Jason, around my sixth week at the clinic, that I truly understood what Eleanor meant. Jason came in on a sunny Thursday morning. During our visit, I learned that he had asthma but had no idea of what his triggers were, how to use his medications, or even what medications hewas on. It was a quiet morning, so I took the time to teach him about asthma: how to identify and monitor his symptoms, take his meds, and when to call for help. Jason was bright and articulate and caught on quickly. I learned he had been in the same foster home for nearly 16 years, with a family he enjoyed and felt part of. We must have spent about 40 minutes together, including time to write new prescriptions. I finally had my hand on the doorknob, ready to leave the room, when I turned and asked him what I often asked my patients at the end of a visit, “Is there anything else I can do for you today?” The room developed that quiet stillness that tells you something important is about to occur. I stood waiting, my hand on the door, as Jason sat, looking at me, assessing and thinking. I waited some more, a bit impatient to move on, a bit uncertain and anxious about what was coming. Finally, after what was surely no more than seconds, but felt like minutes, he replied, “Yes. You can tell me what I did when I was 6 months old to be put in foster care.” I could feel in the space between us how hard it was for him to ask this question, and how much pain and hurt lay behind the words. It hit me then how little I knew about