Health home meets foster care’s complex needs

An integrated health home in North Texas aims to fill disparities in physical and mental health, educational attainment, and special healthcare needs for today’s children in foster care.

The Rees-Jones Center for Foster Care Excellence at Children’s Health, housed on campuses in Plano and Dallas, Texas, is a healthcare model providing pediatricians, nurse coordinators, therapists, psychiatrists, early childhood specialists, and child protective services for about 1400 children a year. That’s close to 5500 visits among all those providers for children the experts there say are among America’s most vulnerable.

“Like most pediatricians, I was serving any child who needed help and support,” says the Center’s Director Anu Partap, MD, MPH, who is also assistant professor of Pediatrics at the University of Texas (UT) Southwestern Medical Center, Dallas. “When I came to Children’s Medical Center in 2009, I started working with children in foster care and was struck by how their complex needs exceed what most of us can do by ourselves in a pediatric practice.”

Children in foster care, she says, have health issues related to histories of abuse and neglect, and often have special healthcare needs that require specialized medical attention. They have the emotional trauma of not being with their families anymore and living in a new community. Then, they likely have mental health troubles, which can be long term.

As a practicing pediatrician, Partap says she’d try to address the children’s issues but wasn’t providing the quality of care they needed. The new model of care helps her provide that quality, she says.

“We know that children who grow up in households with abuse, neglect, domestic violence, parents with addiction, and more will go on to have much higher rates of heart disease, diabetes, obesity, mental illness, and addiction,” Partap says. “When you look at children in foster care, they likely have the highest risk compared to the population of victims of abuse or neglect. Their trauma histories are potentially shaping their entire lives, unless we intensively treat them when they first come in.”

A new idea

The Rees-Jones Foundation provided a grant in 2014 for the 25-year-old foster care medical home in Dallas to transform into a multifaceted Center with locations in Dallas and Plano, focused on improving the well-being and long-term outcomes of foster care children in Texas.

There are about 15 other centers scattered around the United States that address healthcare needs in the foster care community. However, the Rees-Jones Center is among the most comprehensive, providing care even as children transition out of foster care and partnering with organizations and the government to make life better for these children. Many of the Rees-Jones Center providers have faculty appointments at UT Southwestern Medical Center, according to Partap.

Foster care in America

Most pediatricians will care for children in foster care, according to Partap.

Nearly 1% of US children spend time in foster care annually. About 6% of children spend time in foster care at least once between birth and age 18 years, and most children in foster care are victims of abuse or neglect.¹

Researchers have found these children to be in poor mental and physical health, compared with children outside the foster care system. Their physical and mental vulnerabilities are, in part, a result of early life circumstances.¹

Chances are good that children’s healthcare utilization was fragmented and sporadic before they entered foster care, resulting in a high prevalence of undiagnosed or under-treated chronic medical problems once they get to foster care.²

Recommended: Filling medical gaps in foster care

About half of children who are in foster care have chronic physical problems, such as asthma, anemia, visual loss, hearing loss, and neurological disorders. About 1 in 10 are medically fragile or complex, many were born prematurely or have a history of prenatal maternal substance exposure.²

The toxic stress these children often experience can lead to lifelong physical, mental, and behavioral issues. Studies have shown that neural connections in the brain can be disrupted or damaged during periods of extreme and repetitive stress even in infancy, according to the American Academy of Pediatrics (AAP).³

“Toxic stress, epigenetics, and adverse childhood events really drive the need for us to do things differently,” Partap says.

NEXT: What to do

What to do

Being in foster care means the state took custody of a child, usually because of concerns about the safety of the child resulting from abuse or neglect. Often these children will come to their pediatric appointments with foster parents they don’t know well or relatives who have agreed to become their caregivers, Partap says.

“Having a child in foster care is a red flag to provide pediatric care very differently,” Partap says. The children might appear to be all right but harbor undiagnosed chronic conditions. Pediatricians have to be attuned to look for what isn’t apparent and start the visit with complete compassion and an open heart, she points out.

“It’s hard for the child to be in this situation. It’s also very stressful for foster parents and relatives. They’re living with a child they don’t know, whom they’re going to have a lot of trouble with, potentially,” Partap says. “Trying to nurture that family and that child through that is the most important role we have.”

The initial health assessment should be thoughtful and thorough because foster parents often don’t have these children’s health histories and don’t know much about their backgrounds. “Those first appointments are really critical in setting a recovery path for the child and family,” Partap notes.

It’s also important for pediatricians to help foster parents understand what to expect in the coming days or weeks because, in the beginning of foster care placement, it can be hard for these children to get through the day.

“They can have problems with sleep, eating, and toileting, and handling their emotional health,” she says. “Giving foster parents tips early in the process is critical for helping that family and child. The only way you’ll be able to really support that child and family through a recovery period is to see them early and often.”

Strength in referrals

Community pediatricians can better care for children in foster care if they align with other providers and community resources, according to Partap.

For example, pediatricians should be familiar with their local Child Protective Services (CPS). Links to CPS by state are available at ChildHelp.org.

“Local [CPS] organizations can be a great resource for the children, foster parents and biological parents, since about half of the kids in foster care will return home,” Partap says.

Mental health teams are key to a child in foster care’s recovery. These include therapists, who provide evidence-based practice, to psychiatrists, who can prescribe medications to the children who need them. “Knowing who is trauma informed and sensitive to foster care is critical for the pediatricians,” Partap says.

Pediatricians should be aware of medical specialists in the area who will see these children quickly, she says.

In addition, being able to point parents in the direction of special educational programs is important. “We know trauma affects early brain development and sets up pathways of chronic disease, including learning and physical and emotional difficulties,” Partap says.

Many schools offer educational specialists who can assess children affected by trauma. Schools might offer specialized classrooms, tutoring, or a modified curriculum, for example, to better accommodate foster care children, Partap says.

Next: Trauma informed care for kids in foster care

Pediatricians are at the heart of care for children in foster care, they but can’t do it alone, according to Partap. “If all of us do our part . . . to really focus on treating and supporting children and families,” Partap says, “the hope is that we can undo or prevent difficulties and poor health, and they can still become the children they were meant to be.”

Partap says the Rees-Jones Center is set up to collect data on this unique patient population’s healthcare needs, outcomes, and best practices.

REFERENCES

1. Turney K, Wildeman C. Mental and physical health of children in foster care. Pediatrics. 2016;138(5):e20161118.

2. American Academy of Pediatrics. Healthy Foster Care America: Physical health. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Physical-Health.aspx. Accessed March 9, 2016.

3. American Academy of Pediatrics. The Resilience Project: ACEs and toxic stress. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/ACEs-and-Toxic-Stress.aspx. Accessed March 9, 2016.

Ms Hilton is a medical writer who has covered health and medicine for 25 years. She resides in Boca Raton, Florida. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.