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Comprehensive health care for children in foster care

Sandra H Jee, MD, MPH
Moira A Szilagyi, MD, PhD
Section Editors
Jan E Drutz, MD
Marilyn Augustyn, MD
Deputy Editor
Mary M Torchia, MD


Children and adolescents who spend time in foster care have often been exposed to multiple adverse childhood experiences, including child maltreatment, as have many children whose families are involved with the child welfare system and those living away from their parents in informal placements with relatives.

An understanding of the structure, goals, and mandates of the foster care system, as well as the unique health, mental health, developmental, and educational problems of children and adolescents in foster care, facilitates provision of appropriate comprehensive care to this vulnerable population [1,2].

Comprehensive health care for children and adolescents in foster care will be discussed here. The epidemiology of foster care and an overview of the foster care system in the United States are presented separately. (See "Epidemiology of foster care placement and overview of the foster care system in the United States".)


Overview — Children in foster care are a uniquely vulnerable population. They are classified as children with special health care needs by the American Academy of Pediatrics because of the high prevalence of chronic medical, developmental, and mental health problems, most of which predate placement in foster care [3,4]. Most children in foster care have at least one chronic medical problem (table 1); one-fourth have three or more [2,4-9]. (See "Children with special health care needs".)

Throughout this topic, the concept of health encompasses physical (including dental), mental, behavioral, developmental, and educational health. The potential health problems of children in foster care include, but are not limited to [2,4-8,10,11]:


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  1. Mather M. Adoption: a forgotten paediatric speciality. Arch Dis Child 1999; 81:492.
  2. Szilagyi M. The pediatric role in the care of children in foster and kinship care. Pediatr Rev 2012; 33:496.
  3. American Academy of Pediatrics. Fostering Health: Health Care for Children and Adolescents in Foster Care, 2nd Edition. Available at www2.aap.org/fostercare/FosteringHealth.html (Accessed on December 14, 2012).
  4. Ringeisen H, Casanueva C, Urato M, Cross T. Special health care needs among children in the child welfare system. Pediatrics 2008; 122:e232.
  5. Simms MD. The foster care clinic: a community program to identify treatment needs of children in foster care. J Dev Behav Pediatr 1989; 10:121.
  6. 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.
  7. Chernoff R, Combs-Orme T, Risley-Curtiss C, Heisler A. Assessing the health status of children entering foster care. Pediatrics 1994; 93:594.
  8. Jee SH, Barth RP, Szilagyi MA, et al. Factors associated with chronic conditions among children in foster care. J Health Care Poor Underserved 2006; 17:328.
  9. Steele JS, Buchi KF. Medical and mental health of children entering the utah foster care system. Pediatrics 2008; 122:e703.
  10. Special considerations for the health supervision of children and youth in foster care. Paediatr Child Health 2008; 13:129.
  11. Lange S, Shield K, Rehm J, Popova S. Prevalence of fetal alcohol spectrum disorders in child care settings: a meta-analysis. Pediatrics 2013; 132:e980.
  12. Johnson SB, Riley AW, Granger DA, Riis J. The science of early life toxic stress for pediatric practice and advocacy. Pediatrics 2013; 131:319.
  13. Rosenfeld AA, Pilowsky DJ, Fine P, et al. Foster care: an update. J Am Acad Child Adolesc Psychiatry 1997; 36:448.
  14. Simms MD. Foster children and the foster care system, Part II: Impact on the child. Curr Probl Pediatr 1991; 21:345.
  15. McMillen JC, Zima BT, Scott LD Jr, et al. Prevalence of psychiatric disorders among older youths in the foster care system. J Am Acad Child Adolesc Psychiatry 2005; 44:88.
  16. Pilowsky DJ, Wu LT. Psychiatric symptoms and substance use disorders in a nationally representative sample of American adolescents involved with foster care. J Adolesc Health 2006; 38:351.
  17. McEwen BS. The neurobiology of stress: from serendipity to clinical relevance. Brain Res 2000; 886:172.
  18. Gunnar MR, Fisher PA, Early Experience, Stress, and Prevention Network. Bringing basic research on early experience and stress neurobiology to bear on preventive interventions for neglected and maltreated children. Dev Psychopathol 2006; 18:651.
  19. Center on the Developing Child at Harvard University. Toxic stress: The facts. Available at: developingchild.harvard.edu/topics/science_of_early_childhood/toxic_stress_response/ (Accessed on December 13, 2012).
  20. Garner AS, Shonkoff JP, Committee on Psychosocial Aspects of Child and Family Health, et al. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics 2012; 129:e224.
  21. Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of Child and Family Health, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics 2012; 129:e232.
  22. Halfon N, Berkowitz G, Klee L. Mental health service utilization by children in foster care in California. Pediatrics 1992; 89:1238.
  23. Cicchetti D, Rogosh FA, Lynch M, Holt KD. Resilience in maltreated children-processes leading to adaptive outcome. Dev Psychopathol 1993; 5:629.
  24. Pane Seifert HT, Farmer EM, Wagner HR 2nd, et al. Patterns of maltreatment and diagnosis across levels of care in group homes. Child Abuse Negl 2015; 42:72.
  25. Cicchetti D, Toth SL. A developmental psychopathology perspective on child abuse and neglect. J Am Acad Child Adolesc Psychiatry 1995; 34:541.
  26. Harman JS, Childs GE, Kelleher KJ. Mental health care utilization and expenditures by children in foster care. Arch Pediatr Adolesc Med 2000; 154:1114.
  27. Takayama JI, Bergman AB, Connell FA. Children in foster care in the state of Washington. Health care utilization and expenditures. JAMA 1994; 271:1850.
  28. Heneghan A, Stein RE, Hurlburt MS, et al. Mental health problems in teens investigated by U.S. child welfare agencies. J Adolesc Health 2013; 52:634.
  29. Conn AM, Szilagyi MA, Franke TM, et al. Trends in child protection and out-of-home care. Pediatrics 2013; 132:712.
  30. Jee SH, Szilagyi M, Conn AM, et al. Validating office-based screening for psychosocial strengths and difficulties among youths in foster care. Pediatrics 2011; 127:904.
  31. Horwitz SM, Hurlburt MS, Goldhaber-Fiebert JD, et al. Mental health services use by children investigated by child welfare agencies. Pediatrics 2012; 130:861.
  32. Gudiño OG, Martinez JI, Lau AS. Mental health service use by youths in contact with child welfare: racial disparities by problem type. Psychiatr Serv 2012; 63:1004.
  33. dosReis S, Zito JM, Safer DJ, Soeken KL. Mental health services for youths in foster care and disabled youths. Am J Public Health 2001; 91:1094.
  34. Klein B, Damiani-Taraba G, Koster A, et al. Diagnosing attention-deficit hyperactivity disorder (ADHD) in children involved with child protection services: are current diagnostic guidelines acceptable for vulnerable populations? Child Care Health Dev 2015; 41:178.
  35. Courtney, ME, Dworsky, A, Cusick, GR, et al. Midwest evaluation of the adult functioning of former foster youth. Outcomes at age 19: executive summary. www.chapinhall.org/sites/default/files/ChapinHallDocument_3.pdf (Accessed on October 12, 2011).
  36. Pecora PJ, Kessler RC, Williams J, et al. Improving family foster care: Findings from the Northwest Foster Care Alumni Study. Casey Family Programs, Seattle WA, 2005.
  37. Kulka RA, Fairbank JA, Jordan K, Weiss D. Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study, Routledge, New York 1990.
  38. Texas Health and Human Services Commission, 2006. Use of psychoactive medication in Texas foster children, state fiscal year 2005. Available at: www.hhs.state.tx.us/news/release/Analysis.062306.pdf (Accessed on December 13, 2012).
  39. Zima BT, Bussing R, Crecelius GM, et al. Psychotropic medication treatment patterns among school-aged children in foster care. J Child Adolesc Psychopharmacol 1999; 9:135.
  40. dosReis S, Zito JM, Safer DJ, et al. Multiple psychotropic medication use for youths: a two-state comparison. J Child Adolesc Psychopharmacol 2005; 15:68.
  41. Zito JM, Safer DJ, Sai D, et al. Psychotropic medication patterns among youth in foster care. Pediatrics 2008; 121:e157.
  42. Linares LO, Martinez-Martin N, Castellanos FX. Stimulant and atypical antipsychotic medications for children placed in foster homes. PLoS One 2013; 8:e54152.
  43. Minnis H, Everett K, Pelosi AJ, et al. Children in foster care: mental health, service use and costs. Eur Child Adolesc Psychiatry 2006; 15:63.
  44. Joseph MA, O'Connor TG, Briskman JA, et al. The formation of secure new attachments by children who were maltreated: an observational study of adolescents in foster care. Dev Psychopathol 2014; 26:67.
  45. Stein BD, Zima BT, Elliott MN, et al. Violence exposure among school-age children in foster care: relationship to distress symptoms. J Am Acad Child Adolesc Psychiatry 2001; 40:588.
  46. National Survey of Child and Adolescent Well-Being (NSCAW). One year in foster care. Wave 1 Data Analysis Report www.acf.hhs.gov/sites/default/files/opre/oyfc_report.pdf (Accessed on December 14, 2012).
  47. Schor EL. Foster care. Pediatr Rev 1989; 10:209.
  48. Wood D, Halfon N, Scarlata D, et al. Impact of family relocation on children's growth, development, school function, and behavior. JAMA 1993; 270:1334.
  49. Kerbow D. Patterns of urban student mobility and local school reform. Technical Report No. 5. Center for Research on the Education of Children Placed at Risk, Washington, DC 1996.
  50. American Academy of Pediatrics Committee on Early Childhood, Adoption, and Dependent Care: Health care of children in foster care. Pediatrics 1994; 93:335.
  51. Committee on Early Childhood, Adoption, and Dependent Care, American Academy of Pediatarics. Health care of young children in foster care. Pediatrics 2002; 109:536.
  52. Morrow, B. SPARC: State Policy Advocacy and Reform Center. Electronic Information Exchange: Elements that Matter for children in Foster Care. Available at: www.ourkids.us/aboutus/SiteAssets/Electronic%20Information%20Exchange-%20Elements%20that%20Matter%20for%20Children%20in%20Foster%20Care.pdf (Accessed on May 09, 2013).
  53. National Center for Medical Home Implementation. Available at: www.medicalhomeinfo.org (Accessed on December 13, 2012).
  54. Szilagyi MA. The foster care medical home. Future of Pediatrics Conference, Orlando, FL, July 2007.
  55. FaCES Clinic. UMass Memorial Medical Center http://www.umassmemorial.org/support-groups-and-education/health-articles/faces-foster-care-health-services-clinic-3906 (Accessed on October 12, 2011).
  56. Jaudes PK, Bilaver LA, Goerge RM, et al. Improving access to health care for foster children: the Illinois model. Child Welfare 2004; 83:215.
  57. Jee SH, Szilagyi MA, Blatt SD, et al. Timely identification of mental health problems in two foster care medical homes. Child Youth Serv Rev 2010; 32:685.
  58. Rubin DM, Alessandrini EA, Feudtner C, et al. Placement changes and emergency department visits in the first year of foster care. Pediatrics 2004; 114:e354.
  59. Fisher PA, Burraston B, Pears K. The early intervention foster care program: permanent placement outcomes from a randomized trial. Child Maltreat 2005; 10:61.
  60. Schor EL, Neff JM, LaAsmar JL. The Chesapeake Health Plan: an HMO model for foster children. Child Welfare 1984; 63:431.
  61. Mushlin MB, Levitt L, Anderson L. Court-ordered foster family care reform: a case study. Child Welfare 1986; 65:141.
  62. Schor EL. Foster care. Pediatr Clin North Am 1988; 35:1241.
  63. Halfon N, Klee L. Health services for California's foster children: current practices and policy recommendations. Pediatrics 1987; 80:183.
  64. Flaherty EG, Weiss H. Medical evaluation of abused and neglected children. Am J Dis Child 1990; 144:330.
  65. Jee SH, Antonucci TC, Aida M, et al. Emergency department utilization by children in foster care. Ambul Pediatr 2005; 5:102.
  66. Wyatt DT, Simms MD, Horwitz SM. Widespread growth retardation and variable growth recovery in foster children in the first year after initial placement. Arch Pediatr Adolesc Med 1997; 151:813.
  67. Powell GF, Brasel JA, Raiti S, Blizzard RM. Emotional deprivation and growth retardation simulating idiopathic hypopituitarism. II. Endocrinologic evaluation of the syndrome. N Engl J Med 1967; 276:1279.
  68. Powell GF, Brasel JA, Blizzard RM. Emotional deprivation and growth retardation simulating idiopathic hypopituitarism. I. Clinical evaluation of the syndrome. N Engl J Med 1967; 276:1271.
  69. Skuse D, Albanese A, Stanhope R, et al. A new stress-related syndrome of growth failure and hyperphagia in children, associated with reversibility of growth-hormone insufficiency. Lancet 1996; 348:353.
  70. Jee SH, Szilagyi M, Ovenshire C, et al. Improved detection of developmental delays among young children in foster care. Pediatrics 2010; 125:282.
  71. The Child Abuse Prevention and Treatment Act. (P.L. 93-247). Amended and re-authorized on June 25, 2003, by the Keeping Children and Families Safe Act of 2003. (P.L. 108-36).
  72. American Academy of Pediatrics. Committee on Early Childhood and Adoption and Dependent Care. Developmental issues for young children in foster care. Pediatrics 2000; 106:1145.
  73. Public Law 110-351. Fostering Connections to Success and Increasing Adoptions Act of 2008. http://www.fosteringconnections.org/tools/assets/files/Public_Law_110-351.pdf (Accessed on December 14, 2012).
  74. Szilagyi M. The pediatrician and the child in foster care. Pediatr Rev 1998; 19:39.
  75. Samuels B. The Health of Children in Foster Care: Making Improvements Through Medicaid and the Law (webinar). National Institute for Health Care Management (NIHCM) Foundation. April 2013. http://nihcm.org/component/content/article/136-mch-conferences-and-webinars/746-webinar-how-the-health-care-and-legal-systems-can-promote-optimal-health-for-children-in-foster-care (Accessed on April 24, 2013).
  76. Jee SH, Halterman JS, Szilagyi M, et al. Use of a brief standardized screening instrument in a primary care setting to enhance detection of social-emotional problems among youth in foster care. Acad Pediatr 2011; 11:409.
  77. Williams J, Jackson S, Maddocks A, et al. Case-control study of the health of those looked after by local authorities. Arch Dis Child 2001; 85:280.
  78. Conn AM, Calais C, Szilagyi M, et al. Youth in out-of-home care: Relation of engagement in structured group activities with social and mental health measures. Child Youth Serv Rev 2014; 36:201.
  79. Szilagyi, M. Foster Care. In: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 3rd ed, Augustyn, M, Zuckerman, B, Caronna, EB (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. p.450.
  80. Jee SH, Simms MD. Health and well-being of children in foster care placement. Pediatr Rev 2006; 27:34.
  81. White R, Benedict M. Health Status and Utilization Patterns of Children in Foster Care: Executive Summary. Administration for Children, Youth and Families. US Department of Health and Human Services Grant #90-PD-86509, 1986.
  82. Heartz R. Guardians ad litem in child abuse and neglect proceedings: Clarifying the roles to improve effectiveness. CASAnet Resources. Available at: casanet.org/library/guardian-ad-litem/gal-e-section3.htm (Accessed on September 10, 2005).
  83. Council On Foster Care, Adoption, And Kinship Care And Committee On Early Childhood. Health care of youth aging out of foster care. Pediatrics 2012; 130:1170.