The adolescent had a history of marijuana use and multiple incarcerations. Attention deficit disorder and sleep disturbances were documented in his medical history, but absent were dental records, a summary of well-child visits, and a formal psychiatric evaluation. This patient, noted pediatric resident Nicole Brown at a recent Hopkins Children’s Grand Rounds, may not be your typical pediatric patient, but he does fit the profile of a group of patients with special needs pediatricians need to be aware of – children in foster care.
Of the approximately 800,000 children who spend time in foster care each year, Brown reported, more than half are significantly delayed when screened for developmental problems, and 54 to 80 percent meet the clinical criteria for behavioral problems or psychiatric diagnosis. Also, among adolescents these patients have a two-fold higher risk of unplanned pregnancies and sexually transmitted infections.
Providing consistent pediatric care for these patients is not without obstacles. Case managers at child welfare agencies cite high caseloads, insufficient time to schedule appointments, and poor availability of physicians to conduct initial health assessments. In one survey of foster families in Maryland, 37 percent felt that medical and mental health needs were addressed “sometimes” or “almost never,” and many said they were overwhelmed by the complexity of services needed for their foster child (“Improving Health Care for Children in Foster Care,” Child Welfare, 2007).
To make matters worse, when these patients find their way to primary care physicians, family histories and medical records are incomplete, partly because multiple foster parents make poor historians, and because many providers lack training on the psychosocial and health issues confronting foster children. “Besides the lack of training, pediatricians have this general feeling of feeling overwhelmed with these patients,” says Brown. “They don’t have much information to go by, and they don’t know where to start. They’re seeing one picture in time rather than a complete picture of the child.”
One solution, Brown said, might be a Web-based health passport for foster children, a portable electronic patient record accessible by the various providers, case managers and foster families. Such an electronic record could allow multiple physicians to update and fill in any holes in the child’s history and medical record.
“Pediatricians would end up having a better idea of the complicated social situation,” Brown said, “and be able to tailor their management to meet the patient’s needs.”
Brown also recommended that pediatricians follow the American Academy of Pediatrics (AAP) guidelines for caring for foster children, noting that they call for a comprehensive mental health, physical, and developmental evaluation one month after placement of a foster child with a family. Social service case plans, she added, should include the results of these assessments. The AAP also recommends that pediatricians and case managers work together to ensure service delivery, and frequently monitor the foster child’s developmental, mental and physical status. A number of studies, Brown noted, have shown that collaboration between case managers, social workers and community pediatricians improves health outcomes for these patients across the board.