A new model for caring for children in foster care | AdobeStock_559786219

Josue did not speak any English when he first walked into my office. He was with his new foster mother for his initial foster screen: a lively 7-year-old from Puerto Rico, jumping all over the room with curiosity and rapid-fire Spanish. His foster mom begged her worker for help with some disruptive behaviors, but none was found until a crisis landed him in the emergency department, waiting for a bed in a psychiatric unit. Six years and several placements and hospitalizations later, an adoptive home was never found for him; he was permanently moving to a residential program for teen boys. He was developmentally delayed with the height of an 8-year-old; his inexplicable short stature was presumed by the endocrinologist to be related to trauma. His affect was depressed by the multiple psychiatric medicines he had been on for years. He had lost all his Spanish.

The reality of foster care

Most people know that life is hard for children in foster care. They have heard some of the statistics, which are staggering. Twenty percent go on to incarceration within 5 years after aging out of the system,¹ and only half of them finish high school or get a diploma.² A majority of girls in foster care become parents by age 21,^2,3 and 25% become homeless within the first 3 years of aging out.⁴ People assume that being removed from one’s home is difficult for a child. Indeed, there is sometimes significant abuse that occurs while in foster care: verbal, physical, and sexual,^5,6 in addition to the trauma of being separated.

There is also increasing awareness of the effects of trauma on the developing brain, known as toxic stress, leading to a host of later health consequences.^7,8 But it is only the people on the front lines, pediatricians and other primary care providers, who know how difficult it is to provide quality pediatric care to foster children. It is also these providers who know that these vulnerable children are the ones who need quality care the most.⁹

It was all the children like Josue, children who did not thrive but who were let down by the foster care system, who inspired me to improve how I provided care in a meaningful way. This article describes how our community health center has been able to improve the care of our children and youth in foster care by creating our simple Foster Care Program, which includes prompt mental health care and case management in addition to complete pediatric care.

The health challenges foster children face

Children entering foster care have such a high prevalence of health problems that the American Academy of Pediatrics (AAP) now classifies them as a population with special health care needs.⁸ Indeed, a full one-third have a chronic health condition,⁸ including asthma, dental caries, skin disorders, and vision problems, which are often undiagnosed and untreated.⁹ A staggering 80% have developmental and mental health problems.^8,10

AAP guidelines: An important but overwhelming tool

In response, the AAP has created guidelines for quality health care for children in foster care: Fostering Health: Standards of Care for Children in Foster Care.¹¹ In it, the authors lay out a plan for how to care for these children, including an accelerated schedule for visits and advice on how to communicate with foster parents and child welfare workers, assess for the goodness of placement fit, and promptly assess mental health needs.¹¹ While the guidelines make it clear how to provide care for children in foster care, they are overwhelming to the average pediatrician with a busy practice, and indeed, many are not able to adhere to them.^12,13

Additional challenges to care include the transient nature of the population and lack of records, making it difficult to gather a child’s past medical, family, and social history. Sometimes no caregiver is present at office visits, preventing developmental or interim history taking. Communication with Child Protection Services (CPS) and foster parents is often difficult. Referring to appropriate specialists, ancillary services, and mental health care can be almost impossible.¹⁴ What to do?

The priorities for improving care

The literature is clear on what the 2 priorities for improving care should be, as follows:

Prompt mental health care: As mental health issues are the most serious and long-lasting effect of foster care, affecting a large majority of children, it is essential that we connect them with trauma-focused evaluation and treatment as soon as they are removed.^2,14-16

Comprehensive case management: Close case management is equally important to ensure that their care is complete.¹⁴

The Foster Care Program at the Holyoke Health Center

The Foster Care Program is simple. The team of 3 meets on a dedicated morning every week for all foster care visits and later that afternoon for a 1-hour case management meeting. Our patients are our own Holyoke Health Center (HHC) patients, entering our program when they are removed from their home so care is uninterrupted by removal, which is the ideal.¹⁷ In addition, we will accept children who have been removed locally and have no medical home. We keep them as HHC patients, maintaining continuity for these children as well.

1. Staffing

The team consists of a lead provider; in our clinic it is a certified pediatric nurse practitioner (PNP), a colocated mental health counselor (MHC), and a licensed medical assistant for our care coordinator (CC). The lead provider can be any pediatric or family provider, physician, NP, or physician assistant. Our MHC is a therapist as part of our integrated behavioral health team. While this model is ideal, team members do not need to be part of an integrated mental health program but can be social workers, well versed in the effects of trauma and able to listen well and help refer to appropriate mental care services. The CC can be anyone who takes the CPS phone calls and is able to communicate well with CPS and schedule appointments.

2. Dedicated half-day sessions

All children and youth in foster and aggregate care are seen by the foster care team on the same morning every week. Our CC is our first responder, taking the call from CPS when a child is removed. She does not book the first appointment until she has all the needed information: where the child is living, the reason for removal, and assurance that the accompanying adult knows the child well enough for a health history or a phone number of someone who will be available at the time of the visit. The team—PNP, MHC, and CC—are there on-site to see all foster care and routine visits, per the AAP guidelines: initial medical screen at the time of removal, the 1-month comprehensive health assessment, follow-up foster visits, and well-childcare visits.

3. Comprehensive initial visit

At the initial visit, each child is seen by the lead provider and the MHC. After the PNP is finished with the pediatric visit and has performed a full assessment, the MCH meets with the child and the accompanying adult. If the child is verbal, the MCH will meet alone with the child in her office and do a full assessment of the child’s mental health needs using standard screeners (Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-item scale, Pediatric Symptom Checklist-17, Modified Checklist for Autism in Toddlers, and the Survey of Well-being of Young Children) as well as open-ended interviewing. She speaks with the accompanying adult to assess the situation, including the goodness of fit of the home and any behavior issues the child may be exhibiting. She gives an overview of how trauma manifests in children and youth, normalizing the child’s behavior for the accompanying adult. The CC also comes to each visit and provides follow-up clinic, specialty, and ancillary appointments, as well as contact information for the team.

4. Frequent follow-ups until stability

The child comes for follow-ups, for both pediatric and mental health visits, until the team has determined that they are stable enough to leave case management. Stability is determined by several factors. The child needs to be in a home that is safe and nurturing. They need to be in the appropriate school and grade and have educational services in place, if needed. They also need mental health services or early intervention services in place, unless they have completed therapy and are deemed to be in a good place. While these decisions are controlled by CPS and not us, we do our best to work with CPS to ensure that the child is in the best situation possible. Children who are placed back in their original home are still followed until they are stable. Once the child leaves case management, they return to their original primary care physician at HHC and are placed on a “stable” list to be “activated” if any issues arise. They continue to be cared for at the HHC, only leaving if there is a long-distance move with permanency or if the parents choose to change providers, which they usually do not.

5. Short-term therapy when needed

The MHC sees the child/youth for short-term care until an appropriate long-term therapist is engaged, as needed.

6. Weekly meetings

The team meets later that same day to discuss the cases seen in the morning; the goal is to ensure that each child’s many needs are being addressed. We discuss the goodness of fit of the placement and make phone calls or have meetings with CPS, foster parents, schools, or specialists. We also discuss school adjustment and placement, the emotional state of the child, and anything that might be needed. We ensure that the children are getting all ancillary and specialty care, including early intervention, physical therapy, dental care, and eye care.

Sometimes the meeting time is spent on calls or on 1 meeting with a school or foster parent. Sometimes we spend the hour discussing the whole list of children, ensuring that no child is overlooked, making appointments for children who have missed follow-up appointments. Sometimes the meeting is spent discussing 1 child whose situation is complicated. The meetings are essential to ensure that none of the children are falling through the cracks.

Dani

Dani was 12 years of age and still Tanner stage 1 when I met her for her first visit. She and her sister had just been removed and had been followed by one of the pediatricians in the health center. They were accompanied by a CPS staff person who knew very little about them. Dani was wearing a skirt and her hair was dyed purple, but it was clear that she had been assigned male at birth. After her exam, I explained to her that I could send her to a specialist to help her body develop like a woman’s if she liked. She was very excited. Our CC made the appointment at the gender-affirming clinic.

Dani was thrilled to start getting hormone blockers to prevent her from developing secondary male sex characteristics. She also started psychotherapy with our MCH, who felt that she was an excellent candidate for gender-affirming care. After a few months, she returned for follow-up at the foster clinic and we discovered that CPS had stopped the hormone blockers because the correct paperwork had not been filled out. We made several phone calls to find the right person to sign the necessary paperwork and the injections were started again. The sisters were released for adoption after about a year, until it was discovered that one the mothers had been using street drugs and lying about it. They were separated into aggregate programs, and once again the hormone therapy was paused, but we were able to help her get back on track with minimal Tanner development.

Most recently, both sisters are living with 2 moms who plan to keep them permanently. Both girls were seen for therapy by our MHC and are doing well in their new home.

Lavender and Nate

Lavender had blonde hair and a gap-toothed smile that gave her age and her joyful spirit away in one moment. She was so disarming that her blue eyes that did not work together were not the first thing we noticed. But once we did, finding an ophthalmologist was at the top of our list for her. She was also very worried about her parents missing her, because she said, “They love me very much.” She was brought in by her aunt, a bank vice president, whom she did not know and who had disparaging things to say about her estranged brother and his wife. Lavender’s older brother, Nate, was quiet and thoughtful and planned to be a writer. When I met him, he simply wanted to know why he was removed, as he had never been abused or neglected.

In time, it became clear that Lavender was suffering in the home of her aunt, who was unkind to her and even failed to take her to the eye doctor. In addition, no one at CPS would tell Nate anything about his situation and if/when he might return. Through our case management meetings, we were successful in getting Lavender the eye care that she needed. She was moved to a different kinship placement and soon after went home. While Nate was never told why he was removed, when we approached CPS about this, he was immediately sent home.

Both children were seen for short-term therapy and are doing very well back home with their biological mom and Lavender’s biological dad, who continue to bring the children to us for care.

A new model

As the AAP has determined that foster children are a population with special health care needs, it is our duty to create a model of care for them that is effective, manageable, and sustainable and to try to follow their guidelines for care to the best of our abilities. Our team-based approach may appear simple, but with a minimum amount of time and resources, we have dramatically improved care for our children: providing them with both prompt mental health evaluation and services and close case management. In addition, our model allows us to keep our young patients at their own medical home, uninterrupted throughout their foster care journey, unusual for specialized care for these children; the literature illuminates many tertiary care programs, which see children for 1 or 2 visits before returning them to their primary care physician.¹⁸ The only additional cost is for 1 hour of provider time for the meeting. Clinic time is part of the regular schedule of all 3 staff personnel, so no funding is required.

This model can be recreated easily in any pediatric setting no matter how small or large or how many children there are in foster care, even if there is no integrated mental health care program. A team can consist of any 2 or more people who are concerned about improving the care and the lives of their patients in foster care.

Taking such good care of the children and having people to decompress with and help with the secondary trauma of this work, with time to laugh and cry and celebrate the children together, has made all our lives richer and our work more fulfilling.

Click here for more from the May issue of Contemporary Pediatrics.

References

1. Perez J. The foster care-to-prison pipeline: a road to incarceration. The Criminal Law Practitioner. February 24, 2023. Updated October 18, 2023. Accessed January 30, 2025. https://www.crimlawpractitioner.org/post/the-foster-care-to-prison-pipeline-a-road-to-incarceration

2. Hatch-Pigott V. Child welfare: now that we know better, let’s do better. Contemporary Pediatrics. May 8, 2024. Accessed January 30, 2025. https://www.contemporarypediatrics.com/view/child-welfare-now-that-we-know-better-let-s-do-better

3. Combs KM, Begun S, Rinehart DJ, Taussig H. Pregnancy and childbearing among young adults who experienced foster care. Child Maltreat. 2018;23(2):166-174. doi:10.1177/1077559517733816

4. Fowler PJ, Marcal KE, Zhang J, Day O, Landsverk J. Homelessness and aging out of foster care: a national comparison of child welfare-involved adolescents. Child Youth Serv Rev. 2017;77:27-33. doi:10.1016/j.childyouth.2017.03.017

5. Gupta-Kagan J. Confronting indeterminacy and bias in child protection law. Stanford Law Pol Rev. 2022;33:217-287.

6. Doyle J. Child protection and child outcomes: measuring the effects of foster care. Am Econ Rev. 2007;97(5):1585-1610. doi:10.1257/aer.97.5.1583

7. Committee on Early Childhood, Adoption and Dependent Care. Developmental issues for young children in foster care. Pediatrics. 2000;106(5):1145-1150. doi:10.1542/peds.106.5.1145

8. Szilagyi MA, Rosen DS, Rubin D, Zlotnik S; Council on Foster Care, Adoption, and Kinship Care; Committee on Adolescence; Council on Early Childhood. Health care issues for children and adolescents in foster care and kinship care. Pediatrics. 2015;136(4):e1142-e1166. doi:10.1542/peds.2015-2656

9. Deutsch SA, Fortin K. Physical health problems and barriers to optimal health care among children in foster care. Curr Probl Pediatr Adolesc Health Care. 2015;45(10):286-291. doi:10.1016/j.cppeds.2015.08.002

10. Hambrick EP, Oppenheim-Weller S, N’zi AM, Taussig HN. Mental health interventions for children in foster care: a systematic review. Child Youth Serv Rev. 2016;70:65-77. doi:10.1016/j.childyouth.2016.09.002

11. American Academy of Pediatrics Task Force on Health Care for Children in Foster Care. Fostering Health: Standards of Care for Children in Foster Care. American Academy of Pediatrics; 2021. Accessed January 30, 2025. https://www.aap.org/en/patient-care/foster-care/fostering-health-standards-of-care-for-children-in-foster-care/

12. Leslie LK, Hurlburt MS, Landsverk J, Rolls JA, Wood PA, Kelleher KJ. Comprehensive assessments for children entering foster care: a national perspective. Pediatrics. 2003;112(1 pt 1):134-142. doi:10.1542/peds.112.1.134

13. Keim J, Fortin K. Specialized programs employing different models of care delivery work collaboratively to address the health care needs of children in foster care. Curr Probl Pediatr Adolesc Health Care. 2024;54(2):101577. doi:10.1016/j.cppeds.2024.101577

14. Bass P. Filling Medical gaps in foster care. Contemporary Pediatrics. April 1, 2017. Accessed January 30, 2025. https://www.contemporarypediatrics.com/view/filling-medical-gaps-foster-care

15. Deutsch SA, Lynch A, Zlotnik S, Matone M, Kreider A, Noonan K. Mental health, behavioral and developmental issues for youth in foster care. Curr Probl Pediatr Adolesc Health Care. 2015;45(10):292-297. doi:10.1016/j.cppeds.2015.08.003

16. Engler AD, Sarpong KO, Van Horne BS, Greeley CS, Keefe RJ. A systematic review of mental health disorders of children in foster care. Trauma Violence Abuse. 2022;23(1):255-264. doi:10.1177/1524838020941197

17. Schilling S, Fortin K, Forkey H. Medical management and trauma-informed care for children in foster care. Curr Probl Pediatr Adolesc Health Care. 2015;45(10):298-305. doi:10.1016/j.cppeds.2015.08.004

18. Gerson R, Corwin DL, Durette L. Re-imagining child welfare to support children and families. Child Adolesc Psychiatr Clin N Am. 2024;33(3):369-379. doi:10.1016/j.chc.2024.02.008