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Advances in Pediatrics

Care of the Foster Child: A Primer for the Pediatrician

      Foster care was designed to provide temporary, nurturing environments to children while their caregivers (usually birth parents) receive services to help them facilitate eventual reunification. The number of children in foster care in the United States has been steadily increasing in the past 2 decades with more than 500,000 children in care on any given day [
      The Adoption and Foster Care Reporting and Analysis System (AFCARS) Reports #10–17.
      ,
      • Szilagyi M.
      The pediatrician and the child in foster care.
      ,
      • US House of Representatives, Subcommittee on Children, Youth and Families
      No place to call home: discarded children in America.
      ]. However, according to the US Department of Health and Human Services, Adoption and Foster Care Analysis and Reporting System (AFCARS), there has been a gradual decline in numbers since fiscal year (FY) 2007. In AFCARS Report #17, an estimated 424,000 children were in foster care in the United States on September 30, 2009. Since 2007, the number of foster children exiting the system has been greater than those entering. Overall, the number of children in foster care has declined to its lowest level since 2002, and the number of adoptions has increased to its highest level [
      The Adoption and Foster Care Reporting and Analysis System (AFCARS) Reports #10–17.
      ,
      • The Adoption and Foster Care Reporting and Analysis System (AFCARS) Report
      Trends in foster care and adoption FY 2002-FY 2009.
      ]. The recent trend has been to (1) attempt to keep children with their birth families while providing family preservation services, (2) push for more timely reunification of families, and (3) commence concurrent planning early with the aim of expediting termination of parental rights and permanency preparation in cases where reunification is not possible [
      American Academy of Pediatrics. Committee on early childhood, adoption, and dependent care: health care of young children in foster care.
      ,
      The Adoption Assistance Child Welfare Act. Pub L No. 96–272 (1980).
      ]. Despite this progress, there still are a large number of children in foster care who require quality health care assessments, treatment, and close monitoring.
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      References

      1. The Adoption and Foster Care Reporting and Analysis System (AFCARS) Reports #10–17.
        (Available at:) (Accessed November 17, 2010)
        • Szilagyi M.
        The pediatrician and the child in foster care.
        Pediatr Rev. 1998; 19: 39-50
        • US House of Representatives, Subcommittee on Children, Youth and Families
        No place to call home: discarded children in America.
        US Government Printing Office, Washington, DC1989
        • The Adoption and Foster Care Reporting and Analysis System (AFCARS) Report
        Trends in foster care and adoption FY 2002-FY 2009.
        (Available at:) (Accessed November 17, 2010)
      2. American Academy of Pediatrics. Committee on early childhood, adoption, and dependent care: health care of young children in foster care.
        Pediatrics. 2002; 109: 536-541
      3. The Adoption Assistance Child Welfare Act. Pub L No. 96–272 (1980).
        (Available at:) (Accessed January 21, 2011)
      4. Curtis P.A. Dale Jr., G. Kendall J.C. The foster care crisis: translating research into policy and practice. University of Nebraska Press, Lincoln (NE)1999
        • US General Accounting Office
        Parental substance abuse: implications for children, the child welfare system, and foster care outcomes.
        GAO/Health, Education, and Human Services Division, Washington, DC1997 (p. 1–12)
      5. The NSDUH Report: children living with substance-dependent or substance-abusing parents: 2002 to 2007. Rockville (MD); 2009. Available at: http://store.samhsa.gov/product/NSDUH09-0416 Accessed November 17, 2010.

      6. Substance Abuse and Mental Health Services Administration (SAMHSA) Substance-Exposed Infants: state responses to the problem 2009;9–14. Available at: http://store.samhsa.gov/product/SMA09-4369. Accessed on November 17, 2010.

        • May P.A.
        • Gossage J.P.
        • Kalberg W.
        • et al.
        Prevalence and epidemiologic characteristics of FASD from various research methods with an emphasis on recent in-school studies.
        Dev Disabil Res Rev. 2009; 15: 176-192
        • Abel E.L.
        • Sokol R.J.
        Incidence of fetal alcohol syndrome and economic impact of FAS– related anomalies.
        Drug Alcohol Depend. 1987; 19: 51-70
        • Astley S.J.
        Diagnostic guide for fetal alcohol spectrum disorders: the 4-digit diagnostic code.
        3rd edition. University of Washington, Seattle (WA)2004 (Available at:) (Accessed November 17, 2010)
        • Astley S.J.
        • Stachowiak J.
        • Clarren S.K.
        • et al.
        Application of the FAS facial photographic screening and tool in a foster care population.
        J Pediatr. 2002; 141: 712-717
        • Lester B.
        • Lagasse L.
        • Seifer R.
        Cocaine exposure and children. The meaning of subtle effects.
        Science. 1998; 282: 633-634
        • Bada H.
        • Das A.
        • Bauer C.
        • et al.
        Low birth weight and preterm births: etiologic fraction attributable to prenatal drug exposure.
        J Perinatol. 2005; 25: 631-637
        • Nguyen D.
        • Smith L.
        • LaGasse L.
        • et al.
        Intrauterine growth of infants exposed to prenatal methamphetamine: results from the infant development, environment and lifestyle study.
        J Pediatr. 2010; 157: 337-339
        • Miller-Loncar C.
        • Lester B.
        • Seifer R.
        • et al.
        Predictors of motor development in children prenatally exposed to cocaine.
        Neurotoxicol Teratol. 2005; 27: 213-220
        • Lester B.
        • Lagasse L.
        Children of addicted women.
        J Addict Dis. 2010; 29: 259-276
        • Singer L.
        • Minnes S.
        • Short E.
        • et al.
        Cognitive outcomes of preschool children with prenatal cocaine exposure.
        JAMA. 2004; 291: 2448-2456
        • Hobbie C.
        • Braddock M.
        • Henry J.
        Medical assessment of children going into emergency out-of-home placement.
        J Pediatr Health Care. 2000; 14: 172-179
        • Leslie L.K.
        • Hurlburt M.S.
        • Landsverk J.
        • et al.
        Comprehensive assessments for children entering foster care: a national perspective.
        Pediatrics. 2003; 112: 134-142
        • Child Welfare League of America
        Standards of excellence for health care services for children in out-of-home care.
        revised edition. Child Welfare League of America, Washington, DC2007
        • American Academy of Pediatrics
        Task force on health care for children in foster care. Fostering health, health care for children and adolescents in foster care.
        2nd edition. AAP District II, New York2005
        • Steele J.
        • Buchi K.
        Medical and mental health of children entering the Utah foster care system.
        Pediatrics. 2008; 122: e703-e709
        • United States General Accounting Office
        Foster care: health needs of many young children are unknown and unmet. 80. Health, Education and Human Services Division. Child Welfare, Washington, DC1995 (p. 3)
        • Simms M.D.
        • Dubowitz H.
        • Szilagyi M.A.
        Health care needs of children in the foster care system.
        Pediatrics. 2000; 106: 909-918
        • Simms M.
        Foster children and the foster care system, part II. Impact on the child.
        Curr Probl Pediatr. 1991; 21: 345-369
        • Halfon N.
        • Mendonca A.
        • Berkowitz G.
        Health status of children in foster care. The experience of the center for the vulnerable child.
        Arch Pediatr Adolesc Med. 1995; 149: 386-392
        • Schor E.
        The foster care system and health status of foster children.
        Pediatrics. 1982; 69: 521-528
      7. Summary of Clinical Practice Guidelines. Clinical practice guideline: report of the recommendations. Hearing loss, assessment and intervention for young children (age 0–3 years). New York State Department of Health, Early Intervention Program; US Department of Education.Available at: http://www.asha.org/Members/ebp/compendium/guidelines/Clinical-Practice-Guideline–Report-of-the-Recommendations–Hearing-Loss,-Assessment-and-Intervention-for-Young-Children.htm. Accessed January 21, 2011.

        • Takayama J.
        • Wolfe E.
        • Coulter K.
        Relationship between reason for placement and medical findings among children in foster care.
        Pediatrics. 1998; 101: 201-207
        • Grubman S.
        • Gross E.
        • Lerner-Weiss N.
        • et al.
        Older children and adolescents living with perinatally acquired human immunodeficiency virus infection.
        Pediatrics. 1995; 95: 657-663
        • Persaud D.
        • Chandwani S.
        • Rigaud M.
        • et al.
        Delayed recognition of human immunodeficiency virus infection in preadolescent children.
        Pediatrics. 1992; 90: 688-691
        • Kelly D.A.
        • Hallett R.J.
        • Saeed A.
        • et al.
        Prolonged survival and late presentation of vertically transmitted HIV infection in childhood.
        Lancet. 1987; 1: 806-807
        • Espanol T.
        • Figueras M.C.
        • Soriano V.
        • et al.
        Very late presentation of vertically transmitted HIV-1 infection.
        Acta Paediatr. 1996; 85: 755-757
        • American Academy of Pediatrics
        Committee on pediatric AIDS. Identification and care of HIV-exposed and HIV-infected infants, children, and adolescents in foster care.
        Pediatrics. 2000; 106: 149-153
        • Dowdell E.B.
        • Cavanaugh D.J.
        • Burgess A.W.
        • et al.
        Girls in foster care: a vulnerable and high-risk group.
        MCN Am J Matern Child Nurs. 2009; 34: 172-178
        • Hobbs G.
        • Hobbs C.
        Abuse of children in foster and residential care.
        Child Abuse Negl. 1999; 23: 1239-1252
        • Black M.
        • Oberlander S.
        • Lewis T.
        • et al.
        Sexual intercourse among adolescents maltreated before age 12: a prospective investigation.
        Pediatrics. 2009; 124: 941-949
        • Silovksy J.
        • Niec L.
        Characteristics of young children with sexual behavior problems: a pilot study.
        Child Maltreat. 2002; 7: 187-197
        • Kellogg N.
        Clinical report–the evaluation of sexual behaviors in children.
        Pediatrics. 2009; 124: 992-998
        • Felitti V.
        • Anda R.
        • Nordenberg D.
        • et al.
        Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study.
        Am J Prev Med. 1998; 14: 245-258
        • Sempik J.
        • Ward H.
        • Darker I.
        Emotional and behavioral difficulties of children and young people at entry into care.
        Clin Child Psychol Psychiatry. 2008; 13: 221-233
        • Barroso U.
        • Dultra A.
        • Bessa J.
        • et al.
        Comparative analysis of the frequency of lower urinary tract dysfunction among institutionalized and non-institutionalised children.
        BJU Int. 2006; 97: 813-815
        • Sapi M.C.
        • Vasconcelos J.S.
        • Silva F.G.
        • et al.
        Assessment of domestic violence against children and adolescents with enuresis.
        J Pediatr. 2009; 85: 433-437
        • Can G.
        • Topbas M.
        • Okten A.
        • et al.
        Child abuse as a result of enuresis.
        Pediatr Int. 2004; 46: 64-66
        • Joinson C.
        • Heron J.
        • Von Gontard A.
        Early childhood risk factors associated with daytime wetting and soiling in school-age children.
        J Pediatr Psychol. 2008; 33: 739-750
        • Duel B.P.
        • Steinberg-Epstein R.
        • Hill M.
        • et al.
        A survey of voiding dysfunction in children with attention deficit-hyperactivity disorder.
        J Urol. 2003; 170: 1521-1523
        • Baeyens D.
        • Roeyers H.
        • Demeyere I.
        • et al.
        Attention-deficit/hyper-activity disorder (ADHD) as a risk factor for persistent nocturnal enuresis in children: a two-year follow-up study.
        Acta Paediatr. 2005; 94: 1619-1625
        • Crimmins C.R.
        • Rathbun S.R.
        • Husmann D.A.
        Management of urinary incontinence and nocturnal enuresis in attention-deficit hyperactivity disorder.
        Urology. 2003; 170: 1347-1350
        • Shreeram S.
        • He J.P.
        • Kalaydjian A.
        • et al.
        Prevalence of enuresis and its association with attention-deficit/hyperactivity disorder among U.S. children: results from a nationally representative study.
        J Am Acad Child Adolesc Psychiatry. 2009; 48: 34-41
        • American Academy of Pediatrics
        Committee on early childhood, adoption, and dependent care: developmental issues for young children in foster care.
        Pediatrics. 2000; 106: 1145-1150
        • Silver J.
        • DiLorenzo P.
        • Zukoski M.
        Starting young: improving the health and developmental outcomes of infants and toddlers in the child welfare system.
        Child Welfare. 1999; 78: 148-165
        • Horwitz S.
        • Owens P.
        • Simms M.
        Specialized assessments for children in foster care.
        Pediatrics. 2000; 106: 59-66
        • Jee S.
        • Szilagyi M.
        • Ovenshire C.
        • et al.
        Improved detection of developmental delays among young children in foster care.
        Pediatrics. 2010; 125: 282-289
      8. 45 CFR, parts 160 and 164.
        Fed Regist. 2003; 68 (Available at:) (Accessed September 22, 2010): 8334
        • American Academy of Pediatrics
        Committee on child abuse and neglect: policy statement–child abuse, confidentiality, and the Health Insurance Portability and Accountability Act.
        Pediatrics. 2010; 125: 197-201
        • Risley-Curtiss C.
        • Kronenfeld J.
        Health care policies for children in out-of-home care.
        Child Welfare. 2001; 80: 325-350
        • Ringeisen H.
        • Casanueva C.
        • Urato M.
        • et al.
        Special health care needs among children in the child welfare system.
        Pediatrics. 2008; 122: e232-e241
        • Pinborough-Zimmerman J.
        • Satterfield R.
        • Miller J.
        • et al.
        Communication disorders: prevalence and comorbid intellectual disability, autism, and emotional/behavioral disorders.
        Am J Speech Lang Pathol. 2007; 16: 359-367
        • Stock C.D.
        • Fisher P.A.
        Language delays among foster children: implications for policy and practice.
        Child Welfare. 2006; 85: 445-461
        • Shriberg L.D.
        • Tomblin J.B.
        • McSweeny J.L.
        Prevalence of speech delay in 6 year old children and co-morbidity with language impairment.
        J Speech Lang Hear Res. 1999; 42: 1461-1481
        • Hedge M.N.
        Introduction to communicative disorders.
        2nd edition. Pro-Ed, Austin (TX)1995
        • Stahmer A.C.
        • Leslie L.K.
        • Hurlbert M.
        • et al.
        Developmental and behavioral needs and service use for young children in child welfare.
        Pediatrics. 2005; 116: 891-900
        • Tomblin J.B.
        • Records N.L.
        • Buckwater P.
        • et al.
        Prevalence of specific language impairment in kindergarten children.
        J Speech Lang Hear Res. 1997; 40: 1245-1260
        • Nelson H.D.
        • Nygren P.
        • Walker M.
        • et al.
        Screening for speech and language delay in preschool children: systematic evidence review for the US Preventative Services Task Force.
        Pediatrics. 2006; 117: e298-e319
        • Cohen N.J.
        • Davine M.
        • Horodezsky N.
        Unsuspected language impairment in psychiatrically disturbed children: prevalence and language and behavioral characteristics.
        J Am Acad Child Adolesc Psychiatry. 1993; 32: 595-603
        • Ely R.
        Language and literacy in the school years.
        in: Gleason J.B. The development of language. 6th edition. Pearson Education, Boston (MA)2005: 396-443
      9. Child welfare: poverty and families in crisis. State of America's Children.
        Children's Defense Fund, Washington, DC2005 (p. 113–43)
        • Horowitz S.M.
        • Simms M.D.
        • Farrington R.
        Impact of developmental problems on young children's exits from foster care.
        J Dev Behav Pediatr. 1994; 15: 105-110
        • Battle D.
        Language development and disorders in culturally and linguistically diverse children.
        in: Bernstein D.K. Tiegerman-Farber E. Language and communication disorders in children. 5th edition. Allyn and Bacon, Boston (MA)2002 (p. 354–86)
      10. Acquiring English as a second language. What's “normal”, What's not. American Speech-Language-Hearing Association.
        (Available at:) (Accessed October 10, 2010)
        • Culp R.E.
        • Watkins R.V.
        • Lawrence H.
        • et al.
        Maltreated children's language and speech development: abused, neglected, and abused and neglected.
        First Lang. 1991; 11: 377-389
        • Dicker S.
        • Gordon E.
        Ensuring the healthy development of infants in foster care. A guide for judges, advocates, and child welfare professionals.
        Permanent Judicial Commission on Justice for Children & Zero to Three Policy Center, New York (NY)2004
        • Child Welfare Information Gateway
        Parental substance use and the child welfare system. US Department of Health and Human Services.
        (Available at:) (Accessed October 10, 2010)
        • Malakoff M.E.
        • Mayes L.C.
        • Schottenfeld
        • et al.
        Language production of preschool children prenatally exposed to cocaine and multiple drugs and non-exposed children.
        J Appl Dev Psychol. 1999; 20: 158-190
        • Mentis M.
        • Ludgren K.
        Effects of prenatal exposure to cocaine and associated risk factors on language development.
        J Speech Hear Res. 1995; 38: 1303-1318
        • Mattson S.N.
        • Riley E.P.
        • Gramling L.
        • et al.
        Neuropsychological comparison of alcohol-exposed children with or without physical features of fetal alcohol syndrome.
        Neuropsychology. 1998; 12: 146-153
        • Kodituwakku P.W.
        Defining the behavioral phenotype in children with fetal alcohol spectrum disorder: a review.
        Neurosci Biobehav Rev. 2007; 31: 192-201
        • Thorn J.C.
        • Coggins T.E.
        • Olson H.C.
        • et al.
        Exploring the utility of narrative analysis in diagnostic decision making: picture-bound reference, elaboration, and fetal alcohol spectrum disorder.
        J Speech Lang Hear Res. 2007; 50: 459-474
        • Bandstra E.S.
        • Morrow C.E.
        • Vogel A.L.
        • et al.
        Longitudinal influence of prenatal cocaine exposure on child language functioning.
        Neurotoxicol Teratol. 2002; 24: 297-308
        • Lewis B.A.
        • Singer L.T.
        • Short E.J.
        • et al.
        Four-year language outcomes of children exposed to cocaine in-utero.
        Neurotoxicol Teratol. 2004; 26: 617-627
        • Morrow C.E.
        • Vogel A.L.
        • Anthony J.C.
        • et al.
        Expressive and receptive language functioning in preschool children with prenatal cocaine exposure.
        J Pediatr Psychol. 2004; 29: 543-554
        • Zetlin A.
        • Weinberg L.
        • Kimm C.
        Improving education outcomes for children in foster care: intervention by an education liaison.
        J Educ Students Placed At Risk (JESPAR). 2004; 9: 421-429
        • Casey Family Programs
        National Working Group on Foster Care and Education. Educational outcomes for children and youth in foster and out-of-home care. fact sheet: Dec 2008.
        (Available at:) (Accessed December 16, 2010)
        • American Academy of Pediatrics
        Committee on children with disabilities. The pediatrician’s role in the development and implementation of an individualized education plan (IEP) and/or and individual family service plan (IFSP).
        Pediatrics. 1999; 104: 124-127
        • Hill K.
        Individuals with Disabilities Act of 2004 and the John H. Chafee Foster Care Independence Act of 1999: what are the policy implications for youth with disabilities transitioning from foster care?.
        Child Welfare. 2009; 88: 5-23
      11. Individuals with Disabilities Improvement Education Act. 20 U.S.C. Section 1400 1400, et.seq. 2004.

        • Stotland J.
        • Stocco J.
        • Darr K.
        • et al.
        Special education decisions for children in foster care: everyone has a role.
        Child Law Practice. 2007; 26
      12. Report of the Surgeon General’s Conference on Children’s Mental Health United Stated Department of Health and Human Services, 1999.
        (Available at:) (Accessed February 10, 2011)
        • Burns B.J.
        • Phillips S.D.
        • Wagner H.R.
        • et al.
        Mental health need and access to mental health services by youths involved with child welfare: a national survey.
        J Am Acad Child Adolesc Psychiatry. 2004; 43: 960-970
        • Lyons J.
        • Rogers L.
        • The U.S.
        Child welfare system: a de facto public behavioral health care system.
        J Am Acad Child Adolesc Psychiatry. 2004; 43: 971-973
        • Masi R.
        • Cooper J.L.
        Children’s mental health facts for policymakers: National Center for Children in Poverty, November 2006.
        (Available at:) (Accessed February 10, 2011)
        • Raghavan R.
        • Zima B.T.
        • Andersen R.M.
        • et al.
        Psychotropic medication use in a national probability sample of children in the child welfare system.
        J Child Adolesc Psychopharmacol. 2005; 15: 97-106
        • American Academy of Pediatrics
        Children’s Mental Health in Primary Care.
        (Available at:) (Accessed February 10, 2011)
        • Child Welfare League of America
        National fact sheet 2009.
        (Available at:) (Accessed February 6, 2011)
        • Pecora P.
        • Kessler R.
        • Williams J.
        • et al.
        Improving family foster care: findings from the Northwest foster care alumni study.
        (Available at:) (Accessed February 6, 2011)
        • Jensen P.J.
        • Hunter Romanelli L.
        • Percora P.J.
        • et al.
        Special issue: mental health practice guidelines for reform.
        Child Welfare. 2009; 88: 1-31
        • McMillen J.C.
        • Zima B.T.
        • Scott Jr., L.D.
        • et al.
        Prevalence of psychiatric disorders among older youths in the foster care system.
        J Am Acad Child Adolesc Psychiatry. 2005; 44: 88-95
        • Silver J.
        • Dicker S.
        Mental health assessment of infants in foster care.
        Child Welfare. 2007; 85: 35-55
        • Dube S.
        • Felitti V.
        • Dong M.
        • et al.
        Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the Adverse Childhood Experiences study.
        Pediatrics. 2003; 111: 564-572
        • Chapman D.
        • Whitefield C.
        • Felitti V.
        • et al.
        Adverse childhood experiences and the risk of depressive disorders in adulthood.
        J Affect Disord. 2004; 82: 217-225
        • Dube S.
        • Anda R.
        • Felitti V.
        • et al.
        Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span.
        JAMA. 2001; 286: 3089-3096
      13. Addressing mental health concerns in primary care: a clinician’s toolkit. Mental health screening and assessment tools for primary care.
        Pediatrics. 2010; 125: S173-S192
        • Edelstein S.B.
        When foster children leave: helping parents to grieve.
        Child Welfare. 1981; 60: 467-473
        • Edelstein S.B.
        • Burge D.
        • Waterman J.
        Helping foster parents cope with separation, loss, and grief.
        Child Welfare. 2001; 80: 5-26