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Many foster parents are challenged by the social-emotional consequences of children in foster care who have experienced childhood trauma. In this project, we provided foster parents with a trauma-informed, evidence-based parenting program (Incredible Years; IY) and assessed its impact on child behavior, foster parent stress and attitudes, and perceived effect on parenting. Foster parents of children aged 2–7 yrs. were randomly assigned to IY intervention or control groups. We assessed pre-post child behavior, parenting stress, and parental attitudes. A subset of intervention foster parents completed post-intervention focus groups and in-depth interviews. Main themes from qualitative data (3 focus groups; 5 interviews; total n = 12) revealed that IY foster parents perceived changes in their parenting that they attributed to the peer support, new perspectives on the value of play, and specific tools that enhanced parenting skills. These parenting skills improved family relations and were sustained over time. Quantitative data, however, did not as strongly support program effectiveness. Between the IY (n = 16) and control (n = 17) groups, foster parents were less likely to perceive their foster child in need of mental health treatment (p = 0.002), and changed their perception of their child's role in the family (p = 0.03). No between group differences were found for measures of child behavior or parent stress. Overall, these results suggest that trauma-informed IY for foster parents may provide unique peer support and increased confidence needed to implement strategies that can improve intra-family relations. Further research is needed to verify whether and how these relations are improved.

INTRODUCTION Pediatricians recognize a need to mitigate the negative impact that adverse childhood experiences (ACEs) can have on health and development. However, ACEs screening and interventions in primary care pediatrics may be inhibited by concerns about parental perceptions. We assessed parent perspectives of screening for ACEs in the pediatric primary care setting, to understand their views on the potential impact of their ACEs on their parenting and to identify opportunities for pediatric anticipatory guidance. METHOD We used purposive sampling to recruit parents of children

This study explores perspectives on mental health treatment experiences and expectations for youth in foster care and their foster parents. In-depth interviews were conducted and identified for major themes: (1) the dual stigma of foster care and mental health care; (2) the lack of engagement in mental health therapy; (3) trust issues with the therapist and other individuals; and (4) the desire to integrate mental health services with primary care services. These results have implications for mental health service delivery and suggest opportunities to improve mental health treatment through an integrated care approach.

Prior research suggests that for youth in the general population, involvement in activities improves academic, health and social outcomes, but the impact of these activities on youth in out-of-home care is unknown. This study examines, among youth in foster, formal kinship, and residential care, associations between involvement in structured and unstructured activities and social and mental health measures. Among 134 youth in out-of-home care, only 40% were involved in structured activities, and racial/ethnic minorities and males were even less likely to participate (p ≤ 0.01). More youth reported involvement in general physical activity (76%), which was associated with higher social skills when compared to those not involved in such unstructured activity (b = − 10.4; 95% C.I. = − 18.22, − 2.65, p = 0.09). Youth not involved in structured activities showed poorer performance on measures of loneliness (b = 5.6; 95% C.I. = 1.63, 9.47, p = .006), drug abuse (b = 0.95; 95% C.I. = 0.31, 1.59, p = .004), and depression (b = 3.5; 95% C.I. = .25, 6.76, p = 0.04). Participation in activities, particularly when structured, may help these vulnerable youth to achieve better social relationships and mental health.

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.

Objective To determine whether systematic use of a validated social-emotional screening instrument in a primary care setting is feasible and improves detection of social-emotional problems among youth in foster care. Methods Before-and-after study design, following a practice intervention to screen all youth in foster care for psychosocial problems using the Strengths and Difficulties Questionnaire (SDQ), a validated instrument with 5 subdomains. After implementation of systematic screening, youth aged 11 to 17 years and their foster parents completed the SDQ at routine health maintenance visits. We assessed feasibility of screening by measuring the completion rates of SDQ by youth and foster parents. We compared the detection of psychosocial problems during a 2-year period before systematic screening to the detection after implementation of systematic screening with the SDQ. We used chart reviews to assess detection at baseline and after implementing systematic screening. Results Altogether, 92% of 212 youth with routine visits that occurred after initiation of screening had a completed SDQ in the medical record, demonstrating high feasibility of systematic screening. Detection of a potential mental health problem was higher in the screening period than baseline period for the entire population (54% vs 27%, P Conclusions Systematic screening for potential social-emotional problems among youth in foster care was feasible within a primary care setting and doubled the detection rate of potential psychosocial problems.

Background: 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. Methods: 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. Results: 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). Conclusions: 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.

Despite known high rates of mental health problems among children in foster care, these problems are often not identified promptly by primary care or other systems. A novel delivery system is a centralized primary care practice for foster care. The purpose of this study was to examine the identification of mental health within two pediatric medical homes for foster care. We conducted a retrospective medical chart review of all children, aged 6–18 years, newly entering foster care, in two foster care clinics serving two county-wide populations. Our sample of 242 children describes demographics, rates for mental health problem identification, and length of time after entering foster care that mental health needs were identified. We used logistic regression analyses to examine variables associated with identification of mental health needs. Both centralized foster care medical homes had high rates for identification of mental health problems (> 70% in both sites), timely identification (the majority identified within two months after entry into care), and high mental health referral rates for children entering foster care (> 70%). Our findings suggest that attention to mental health needs for children in foster care within their primary care setting can impact identification rates and management of mental health.

Objective To study the relationship between experiencing separation from parents and having learning difficulties among children in a community-based sample. Methods In 2003, parents of children entering kindergarten in the city of Rochester completed a survey assessing the child's social background, medical history, and behavioral profile. Children separated from parents for >1 month were compared with those who had never been away for >1 month on 4 validated developmental measures (range, 1–4): a learning scale, an expressive language scale, a preliteracy scale, and a speech scale. Bivariate analyses and multivariate logistic regression analyses were used to determine associations between separation from parents and learning difficulties. Results Among the 1619 children, 18% had been separated from a parent for >1 month at least once (11% once, 7% ≥2 times). Separated children scored worse compared with those without separations on learning (3.14 vs 3.28, P = .001) and preliteracy (2.21 vs 2.35, P = .03). Higher rates of learning difficulties (26.7% vs 16.7%, P P = .01) were noted among those who had been separated versus those who had not. In multivariable modeling, separation was associated with learning problems (adjusted odds ratio, 1.71; 95% confidence interval, 1.18–2.49) and preliteracy problems (adjusted odds ratio, 1.46; 95% confidence interval, 1.04–2.05) when adjusted for demographic, medical, and social factors. Conclusions Urban children who have experienced separation from a parent may have more learning difficulties at entrance to kindergarten. Screening and intervention practices to remedy these challenges may better equip such young children to succeed when they enter school.

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.

Nearly 750 000 children are currently in foster care in the United States. Recent trends in foster care include reliance on extended family members to care for children in kinship care placements, increased efforts to reduce the length of placement, acceleration of termination of parental rights proceedings, and emphasis on adoption. It is not clear what impact welfare reform may have on the number of children who may require foster care placement. Although most children enter foster care with medical, mental health, or developmental problems, many do not receive adequate or appropriate care while in placement. Psychological and emotional problems, in particular, may worsen rather than improve. Multiple barriers to adequate health care for this population exist. Health care practitioners can help to improve the health and well-being of children in foster care by performing timely and thorough admission evaluations, providing continuity of care, and playing an active advocacy role. Potential areas for health services research include study of the impact of different models of health care delivery, the role of a medical home in providing continuity of care, the perception of the foster care experience by the child, children's adjustment to foster care, and foster parent education on health outcomes.

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

It is unclear why the school-aged children of adolescent mothers do less well behaviorally than the children of adult mothers. It has been hypothesized that adolescents may begin to experience mothering problems when their children are approximately one year of age and are becoming independent. We studied the relationship between adolescent maternal age and mother-child interactions of 30 adolescent mothers (x=17.2 yrs.; S.D.=3.4) and their 9-12 month old children in the laboratory. Two ten minute sequences (floor and chair sequences) were videotaped. A trained observer rated the videotapes of the 30 dyads after establishing inter-rater agreement of >0.7 with a second trained observer on a 19 item rating scale. Floor and chair scores were significantly correlated and thus were averaged for each of the 19 items. There were significant negative correlations between maternal age and the following maternal items: ambivalent rejection (-0.6359, p