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Comprehensive health care for children in foster care

Comprehensive health care for children in foster care
Literature review current through: Jan 2024.
This topic last updated: Sep 21, 2023.

INTRODUCTION — Children and adolescents who spend time in foster care have usually endured multiple adverse childhood experiences, including child maltreatment and family disruption. Studies indicate that children involved with child welfare and living away from their birth parents in informal placements with relatives have had similar life experiences. Thus, providing health care for children involved with child welfare, and especially those in foster care, requires an understanding of childhood trauma and its potential negative impact on the developing brain; the unique health, mental health, developmental, and educational problems of children and adolescents in foster care; and the structure, goals, and mandates of the foster care system as this will facilitate 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".)

HEALTH NEEDS

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 (AAP) because of the high prevalence of chronic medical, developmental, and mental health problems, most of which predate placement in foster care [3-5]. Most children in foster care have at least one chronic medical problem (table 1) and one-fourth have three or more [2,4,6-10]. In a cross-sectional study, the mortality rate among children in foster care was increased compared with children in the general population, independent of race/ethnicity or age [11]. (See "Children and youth with special health care needs".)

Throughout this topic, the concept of health encompasses physical (including dental), mental, behavioral, developmental, educational, and psychosocial health. Some of the most commonly identified health problems of children in foster care include, but are not limited to [2,4,6-9,12,13]:

Exposure to childhood adversity and trauma resulting in toxic or traumatic stress

Educational, behavioral, and mental health problems

Developmental disabilities, especially in cognitive, communication, and personal-social skills

Psychosocial deprivation

Prenatal drug and/or alcohol exposure

Chronic medical illness, for example:

Neurologic conditions, some of which are the result of abusive head trauma or neglect

Genetic and congenital problems

Asthma

Dental problems

Hearing and vision impairment

Overweight/obesity

Prematurity

Exposure to tuberculosis, sexually transmitted infections, hepatitis, and infestations

Elevated lead levels

Lack of prior health care

Under-immunization

Complex childhood trauma and toxic stress — Complex childhood trauma underlies many of the health problems affecting children and adolescents in foster care [14]. Understanding the impact of multiple adverse childhood experiences is fundamental to providing appropriate care for these children [15-18]. Their health problems are compounded by the trauma of removal and separation from their parents/caregivers and the ongoing uncertainty of living in foster care [2,7,19-22].

Children in foster care have often experienced multiple adversities by the time they enter foster care. Infants and young children entering foster care have high rates of prenatal substance exposure, prematurity, and chaotic and inappropriate caregiving by parents and other care providers [7]. Children entering foster care may have experienced significant levels of interpersonal violence in their families and communities in addition to maltreatment in the form of abuse or neglect that resulted in removal and placement in foster care. Adolescents in foster care also have high rates of prior maltreatment, often undisclosed, and rates may be higher among adolescents in congregate versus family foster care [23].

Maltreatment is the ultimate breach of the parent-child relationship. Most young children in foster care have experienced ongoing or intermittent neglect of their most basic needs; they also may have been physically, emotionally, or sexually abused. Rigid, harsh discipline by a caregiver with unrealistic expectations is common in maltreating families, as is the absence of normal predictable nurturance and routines [24].

The terms complex childhood trauma, developmental trauma disorder, and toxic stress are used to describe the cumulative impact of childhood adversities and the subsequent dysregulation of the neuroendocrine stress system, epigenetic changes, and stimulation of inflammatory pathways that negatively affect brain development and overall health [14,15,25-29]. The areas of the brain most affected are those involved in executive function, memory, emotional regulation, attention, and stress reactivity. The impact on cognitive and emotional development manifests as insecure attachment, intellectual disabilities, inattention, poor emotional self-regulation, impulsivity, hyperactivity, emotional reactivity, hyper-arousability, hypervigilance, and other behavioral and emotional problems [4,14,30]. Ongoing exposure to early maltreatment in a setting lacking in protective factors can erode the resilience of children over time [31].

Mental health issues

Prevalence and predisposing factors — Mental health is the most significant health concern for most children and adolescents in foster care. Behavioral and emotional problems rooted in childhood trauma and deprivation are common [10,32-36]. Primary care providers should be vigilant in monitoring children and adolescents in foster care for past or current mental health problems. (See 'Mental health' below.)

The frequency and severity of emotional problems related to complex childhood trauma may be compounded by the child's lack of security and permanence in foster care; lack of stability in placement exacerbates underlying emotional and behavioral problems [37]. More than one-third of children in foster care have moderate to severe emotional problems, and another one-third have less severe disabilities.

Behavioral exacerbations may be precipitated by a number of factors, including:

Poor quality visitation with birth parents, particularly if it is erratic or causes the child to relive the trauma of separation or rejection.

The stress of changes in placement, unrealistic expectations of foster/kinship parents, and court appearances.

Changes in caseworkers, childcare providers, or therapists that magnify losses in the lives of these children.

Reminders of prior trauma, which may be subtle and escape the notice of the caregiver; a child or adolescent presenting with the symptoms noted below should be assessed for exposure to trauma reminders (see 'Manifestations of mental health issues' below)

Foster family's lack of respect for the child's culture (including religion, race, and ethnicity) and/or not allowing the child to practice their culture in a reasonable manner [38]

Foster parent, social worker, or adolescent self-reports may underestimate emotional or developmental problems [39]. In a study of children entering foster care in California, for example, 84 percent were found to have emotional or developmental problems during comprehensive assessment, but only 33 percent of foster parents or social workers reported such problems [7]. In another study, 41 percent of early adolescents (11 to 14 years) entering foster care in Wisconsin had a prior mental health diagnosis, and 72 percent of those without a prior mental health diagnosis received one when formally assessed [40].

Mental health access is low compared with mental health need but improves as children enter school or have more contact with health care providers [41]. Disparities in mental health access remain a significant issue for children in foster care [40,42], with White children having more access than children of other race/ethnicities [43]. Access to mental health is also increased among young children (age two to five years) who have experienced sexual abuse (compared with neglect) [44]. In addition, children in nonrelative foster care appear to have better access to mental health than those in relative foster care [45,46]. As young people "age out" of foster care, their access to mental health care also decreases [47].

Children in foster care account for a disproportionate amount of Medicaid mental health expenditures and are more likely to use Medicaid-reimbursed mental health services and high-cost services (eg, emergency department, inpatient) than children eligible for Medicaid through Temporary Assistance for Needy Families (TANF, formerly Aid to Families with Dependent Children [AFDC]) [30,48,49]. Children in foster care also are more likely than those in TANF to have a mental health problem [32]. The mental health symptoms of children in foster care often are manifestations of trauma and can be difficult to distinguish from other problems such as ADHD, oppositional defiant disorder, depression, and bipolar disorder [50]. The possibility that a child has experienced significant trauma that has not been identified or appropriately addressed should be considered in children with multiple mental health diagnoses or children diagnosed with both behavioral and developmental/learning issues.

Mental health issues related to early trauma also are prevalent among adolescents in foster care, as illustrated by the following observations:

Among 17-year-olds entering foster care in Missouri, 61 percent had at least one psychiatric disorder during their lifetime; 62 percent reported that their earliest psychiatric problem was manifest before entering foster care [21].

Nearly one-third of older adolescents in foster care in the Midwest Study had affective or substance use disorders [51].

Twenty-five percent of young adults in the Northwest Foster Care Alumni Study had posttraumatic stress disorder (a rate nearly twice that in Vietnam war veterans) [52,53].

The AAP and the American Academy of Child and Adolescent Psychiatry strongly recommend that children entering foster care have a full mental health evaluation within several weeks of placement by a trauma-informed, pediatric mental health professional. The failure to view behavioral and emotional symptoms through a trauma lens may lead to misdiagnosis and inappropriate treatment. Traumatic stress symptoms are best treated with stability in a nurturing placement and evidence-based psychotherapies, although medications may be prescribed in the short-term for the treatment of specific symptoms, such as insomnia. Caregivers may need to be counseled to use trauma-informed positive parenting [54] and that medication can temporarily assist with symptoms while awaiting trauma-informed mental health services. Several studies have demonstrated problems including a high prevalence of psychotropic medication use, polypharmacy, prescription of medication for a diagnosis for which the medication is not indicated, and use of two or more drugs from the same class [55-59]. Although some children in foster care who have experienced trauma may have comorbid mental health conditions for which medication is indicated, clinicians and foster parents should be vigilant to ensure that psychotropic medication use is necessary and appropriate [60].

Manifestations of mental health issues — Children may present with symptoms such as hyperactivity, impulsivity, and inattention that mimic other disorders, such as attention deficit hyperactivity disorder (ADHD). Dysregulation of sleep, eating, and elimination (ie, voiding and stooling) are common and may reflect altered structure and function of specific areas of the brain, especially the hippocampus. Thus, the provider needs to include trauma as part of their differential diagnosis of common childhood emotional and behavioral symptoms.

The manifestations of emotional disorders related to trauma and toxic stress vary by the type, intensity, and frequency of stressors/trauma; the age, temperament, and coping capacities of the child; and the presence or absence of protective factors in the child's life:

Infants and young children frequently have sleeping and feeding disorders, extreme fussiness or irritability, and tantrums. Infants younger than six months may have tremors related to withdrawal from prenatal substance exposures. Prenatal substance exposure is also associated with lower language and motor functioning, although early and stable placement may buffer vulnerability to perinatal risk on development [61,62]. (See "Prenatal substance exposure and neonatal abstinence syndrome (NAS): Management and outcomes", section on 'Long-term outcomes'.)

Preschool and early school-age children may have problems with toileting, sleep, transitions, and emotional self-regulation. Dysregulation may manifest as frequent tantrums, aggression, impulsivity, destructive behaviors, and hyperactivity.

Anxiety is more common and depression is less common among children in foster care than expected. However, depression may be a later manifestation of early childhood trauma and manifest in adolescence. Depression may manifest as withdrawal and social isolation or recurrent somatic symptoms that escalate during times of stress or anxiety. Anxiety may manifest as inattention, hyperactivity, high reactivity, or extreme worry. (See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis".)

Some children in foster care have symptoms that meet the criteria for posttraumatic stress disorder with hyper-arousal and high reactivity, re-experiencing (intrusive memories, nightmares about the trauma), and avoidance (memory deficits about trauma, guilt, worry, or numbing). Most children and adolescents, however, manifest traumatic stress symptoms that do not meet criteria for posttraumatic stress disorder. The term "developmental trauma disorder" has been applied to children with a history of complex trauma whose symptoms include a mix of behavioral, developmental, and emotional problems in recognition of the effects on multiple areas of the development brain [63].

Adolescents may test the limits of acceptable social behavior through truancy, delinquency, running away [64], substance abuse, sexual experimentation, and self-destructive or violent activities. High-risk behaviors are believed to represent both the effects of trauma on the prefrontal cortex (and atypical development of emotional and behavioral regulation) and attempts to treat trauma symptoms such as intrusive thoughts [65].

Trauma that occurs in the primary attachment relationship can lead to insecure attachment and have long-lasting implications for interpersonal relationships [66]. Children may view the world as a hostile and unpredictable place and have great difficulty forming healthy attachments to adult caregivers or significant others. Poor relational care in infancy and early childhood may also alter the child's sense of self [67]. However, in an observational study, nearly one-half of 62 adolescents who were insecurely attached to their birth parent were able to form a secure attachment to their foster parent [68].

Exposure to violence — Violence exposure among children in foster care was evaluated through interviews of 300 school-aged children from Los Angeles County [69]. The following results were reported:

Eighty-five percent had witnessed violence in their lifetime; of these, 54 percent had witnessed violence in the previous six months

Fifty-one percent had been a victim of violence in their lifetime; of these, 41 percent had been victims of violence in the previous six months

Children in foster care have also experienced high levels of domestic violence, with a potential lifetime exposure of approximately 60 percent [70]

Child abuse and the effects of witnessing violence are discussed separately. (See "Physical child abuse: Recognition" and "Evaluation of sexual abuse in children and adolescents" and "Child neglect: Evaluation and management" and "Intimate partner violence: Childhood exposure", section on 'Effects'.)

Development and education — The cognitive and academic achievement of children and adolescents in foster care is similar to that of children of underrepresented groups with low socioeconomic status living with their birth families [71]. However, children in foster care have more developmental and educational problems and lower rates of high school completion. Educational problems include learning disabilities, limited cognitive ability, and behavior disorders [2]. The negative impact of trauma on the development of executive function often manifests as inattention and distractibility, which may underlie many of the learning issues noted among those in foster care. Many children who achieve stability in a nurturing home appear to experience significant improvement in developmental and academic functioning [72,73]. Close monitoring for developmental and educational problems is warranted even if a child in foster care appears to be doing well initially, given the multiple adversities and uncertainty children continue to experience after placement. (See "Specific learning disorders in children: Clinical features", section on 'Clinical features'.)

Birth to six years – More than one-half of the preschool children in foster care have developmental disabilities, particularly communication disorders, poor social-adaptive skills, personal-social delays, and delayed fine-motor skills. Screening for developmental disabilities is discussed below. (See 'Screening' below.)

Six to 18 years – Children in foster care are often behind expected grade level in school performance. The poor school achievement of children in foster care is attributed to a variety of factors, including emotional problems, the impact of complex trauma on the developing brain, prenatal alcohol and illicit substance exposure, frequent changes in school placement, school absence, and the chaos of the children's lives before being placed in foster care. Once in foster care, children may be moved out of their school district, and thus need to acclimate to a new environment. Every school placement change results in approximately a four-month loss in academic skills [74,75]. Nonetheless, school attendance usually improves in foster care and child welfare is required by law to try to maintain a child in their school of origin [76]. Screening for educational problems is discussed below. (See 'Screening' below.)

HEALTH CARE PROVISION — Children and adolescents enter foster care during a time of crisis, most often as the result of neglect or abuse. Many of these children have unknown health histories and have not received continuous preventive primary health care, including immunizations [77]. The extent of children's trauma histories and health issues is often unknown. Despite the lack of health information, it is best to initiate care as soon as possible after entry into foster care.

Health care management is fundamental to ensuring that the complex needs of these children are met. Health care management is ultimately the responsibility of the foster care agency but requires the expertise of health professionals. Health care management has multiple components, including ensuring that [2]:

All medical consents are in place

Past health history is pursued and obtained (including the child's birth history, immunization record, trauma history, family history, and family mental health history, if possible)

Health information is shared with foster parents and professionals involved in the care of the child

All necessary and indicated health care, including preventive care and anticipatory guidance, is received by the child and caregiver in a timely manner

Health information is maintained in a useful format and woven into the permanency plan for the child

All caregivers and youth receive education about the child's health problems and treatment

Components — Health care standards published by the American Academy of Pediatrics (AAP) detail the components of high-quality health care for children and adolescents in foster care [3]. Health care for children and adolescents in the foster care system has several major components, discussed below [46]:

Admission health series to identify existing and emerging health needs and to monitor the child's transition into and adjustment to foster care. In addition to information gathering, the admission health series includes initial screening (within 72 hours of placement), comprehensive health assessment (within one month of placement), and a follow-up visit (30 to 60 days after the comprehensive assessment). (See 'Initial screening' below and 'Comprehensive health assessment' below and 'Follow-up visit' below.)

Developmental or educational evaluation, with periodic reassessment. Developmental or educational evaluation can begin with screening, but a full evaluation should be obtained if the child fails the screening, if there is concerning history, or if the caregiver or child welfare caseworker has concerns.

Mental health evaluation, ideally by a pediatric mental health professional with experience in trauma-informed care, with periodic reassessment, especially for the child not receiving mental health care. Periodic reassessment should examine interval trauma experiences, emergence of symptoms, functioning, and psychotropic medication use and appropriateness of medications and dosing for children taking medication.

Dental assessment.

In addition to the AAP's recommended preventive health care schedule, additional visits may be needed to ensure that all of the child's health, developmental, educational, and mental health care needs are addressed appropriately. Children are particularly vulnerable to setbacks in the time around transitions (return to birth parent, visitation changes, being freed for adoption, placement changes, respite placements, adoption). (See 'Recommended health surveillance schedule' below.)

A checklist that includes the crucial aspects of the health assessment and health care for children in foster care is available through the AAP.

Health information gathering — Health information gathering in foster care is an ongoing process. Ideally, the investigating child protective worker or foster care caseworker has a standardized health history form completed by the birth parent. Otherwise, the medical home provider with appropriate authorization or foster care caseworker may need to seek health information from previous sources of care (if known), schools, childcare settings, immunization registries, and newborn screening programs.

Although some have advocated for a medical passport (a portable health record that travels with the child or a web-based or electronic passport), a standardized, universally accepted health passport has not been developed. A few states have a centralized health information system into which health information is entered [78]. While the child is in foster care, it is helpful to collect and maintain up-to-date immunization records, the medical problem list, medication list, and pertinent psychosocial information. Such information should follow the child through placement changes or changes in providers. Ideally, the medical home remains constant even if a placement change occurs, so that the medical home serves as the central repository of health information while the child is in foster care. Laws and regulations around information sharing vary among states so that it is best to seek direction from the state child welfare system or health attorney regarding who can/should have access to health information, including via the patient portal of electronic health records. Health information ideally should follow the child out of foster care, whether they are returning to a parent, adopted, in the care of kin/guardian, or emancipating from care. (See "Children and youth with special health care needs", section on 'Framework of care'.)

General principles — Foster care should be viewed as a window of opportunity for healing for children and adolescents who have experienced complex trauma. A nurturing placement may mitigate, but not eliminate, some of the effects of early childhood trauma on the child's mental health [79]. Health care for children and adolescents in foster care should [3]:

Be provided in the context of a medical home that has expertise and skills in trauma-informed pediatric care [80]

Be well-managed and coordinated

Follow the standards of health care for children and adolescents in foster care as set forth by the AAP and the Child Welfare League of America [3]

Models of delivery — Models for managing and delivering health services to children in foster care are emerging in response to the multiple and unique needs of this population. The models include:

Medical home and integrated care models that specialize in providing primary care services in collaboration with child welfare [81]

A child-centered foster care medical home is one that provides care that is accessible, comprehensive, compassionate, coordinated, culturally competent, and centered on the child in the context of their family relationships and the microculture of foster care. Medical homes with colocated mental health services are considered integrated care models and will be discussed below as medical homes. (See "Children and youth with special health care needs", section on 'Framework of care'.)

A collaborative relationship between the medical home and the child welfare system improves communication and health care management, and aids in timely identification of health problems [82].

The staff in the medical home should be sensitive to the complex trauma these patients have experienced and knowledgeable regarding the impact of complex trauma on the patients' emotional health and development. They should be able to provide advice to foster parents about caring for the traumatized child. Ready access to trauma-informed mental health services either on-site (integrated care) or via a referral network is recommended. (See 'Complex childhood trauma and toxic stress' above.)

Evaluation models that provide initial health evaluations upon entrance to foster care and referral to a pediatric medical home [83]

Preferred provider models in which primary care clinicians receive extra training and a slightly enhanced fee for caring for a child in foster care [83,84]

Health care management models in which health care coordinators are colocated with child welfare and arrange and monitor the care that children receive

Although these models of health care for children in foster care may not be feasible in all communities, some states and localities have adopted some facets of these programs. Adoption of such models, and compliance with health standards for children and adolescents in foster care, will likely improve health outcomes for this vulnerable and needy population.

Barriers — The health of children in foster care often is compromised by inadequate funding, planning, and coordination of services, as well as by poor communication between health, mental health, and child welfare professionals [46]. Other difficulties in the provision of quality health care for children in foster care include the [12,37]:

Absence of an organized system of health care

Lack of adequate health care coverage for all their health needs

Lack of a documented health history provided by the biological parents or caregiver at entry to foster care

High mobility of the child among foster care placements and into and out of foster care

High turnover rates of case workers and other professionals in the system

Lack of health provider knowledge about the impact of trauma on children and its treatment

State Medicaid systems rarely adequately reimburse for all the services that these children require, especially mental health services. In general, Medicaid may not pay for services that have been shown to be of benefit to highly traumatized children, such as therapeutic foster care, mentored visitation, and evidence-based mental health services such as Parent-Child Interaction Therapy [85]. Some communities have addressed these problems by enrolling Medicaid-eligible children and adolescents in foster care into prepaid capitated health plans (Medicaid managed care) to provide an immediate, organized system for comprehensive care [86]. However, mental health care has not always been adequately addressed or covered by managed care. Other communities have provided a centralized source of comprehensive care or identified preferred providers who are willing and able to provide the scope of required services by cobbling together a variety of funding streams [87]. Many such programs ensure quality health services but operate at a substantial deficit. Some states mandate immediate enrollment of children in foster care into Medicaid Managed Care (MMC). Ideally, states would negotiate with MMC to define a package of benefits that would promote integrated care models, preventive mental health services, evidence-based trauma-informed mental health treatment, and appropriate coverage for children with complex medical, mental health, and/or developmental health problems. As of January 1, 2014, any young adult emancipating from foster care at age 18 years or older can retain their Medicaid coverage until age 26 years. Federal law also requires that Medicaid coverage be available to the young adult graduate of foster care who moves out of state.

The diffusion of authority and responsibility for the health care of children and adolescents in foster care results in a number of complexities. Child welfare is ultimately responsible for the health care of children and teens in foster care, but birth parents retain legal guardianship and consent rights until the child/teen is freed for adoption or ages out. Thus, foster caregivers and relatives have physical custody but do not have the right to consent for health care in most states. Laws around who may consent for human immunodeficiency virus (HIV) screening and have access to screening results also vary from state to state. Adolescents in foster care who have capacity to consent are covered by laws governing minors in their state. Caseworkers often have limited health information available to them at the time of removal and placement. In addition, they may have insufficient knowledge or training to know what types of information should be collected, or how to access needed health care services. (See "Consent in adolescent health care".)

Children and adolescents in foster care may have had fragmented or sparse access to health services before placement. Foster parents are typically provided with little past health history and may need to choose the child's health care provider with little guidance [88,89].

Delays in referrals are common as professionals may wait to see whether the child will remain in foster care before making the referral. Many young children do not receive adequate preventive health care while in placement [90].

INITIAL SCREENING — The initial screening ideally should occur within 72 hours of removal from the birth parent and placement in a foster or kinship home, shelter, or group setting [46,88]. Preverbal children, those with complex or chronic health conditions, those with major mental health problems, those with concern for sexual exploitation, and/or those on medication should be prioritized when resources are limited. The birth parent(s) and/or the most recent caregiver (eg, grandmother, aunt) should be encouraged to attend the initial health screening if at all possible. Their attendance may provide the only opportunity for the clinician to obtain detailed and accurate developmental and family histories. However, health screening should not be delayed if the birth parents are unable to attend.

The objectives of the initial health screen are to:

Assess for neglect, physical abuse, and/or sexual abuse (see "Physical child abuse: Recognition" and "Differential diagnosis of suspected child physical abuse" and "Evaluation of sexual abuse in children and adolescents")

Screen for infectious diseases (eg, impetigo) and infestations (lice (picture 1A-C), scabies (picture 2A-D))

Identify acute mental health issues in need of urgent referral or treatment

Identify acute and chronic health problems in need of immediate attention

Ensure that the child has all necessary medications, immunizations, equipment, and referrals

Provide guidance about empathic strategies to promote the child's adjustment to placement and management of behaviors related to prior trauma

The clinician should ensure that the child has any necessary medications or medical equipment and that the new caregiver receives appropriate health education. The caregiver should receive guidance regarding the impact of complex trauma and removal on children and trauma-informed ways to support the child through the transition into foster care (table 2).

COMPREHENSIVE HEALTH ASSESSMENT — A comprehensive health assessment is ideally strengths based while including formal screening for mental health and developmental problems and is ideally accomplished around 30 days after removal and placement in foster care [20,46]. A checklist that includes the crucial aspects of the comprehensive health assessment and health care for children in foster care is available through the American Academy of Pediatrics (AAP).

The goals of the comprehensive health assessment are to identify and formulate a management plan for each health problem, and to ensure that the health plan is communicated to the child welfare caseworker and foster parent. It is important to see the child or adolescent privately for at least a few minutes to ensure that the child feels supported and cared for in their placement, and to perform health risk behavior screening (particularly for adolescents). (See 'Health needs' above.)

Anticipatory guidance, particularly related to chronic illness and behavioral concerns, may help to avoid unnecessary visits to the emergency department [37,91]. Referral for mental health, developmental, educational, and dental assessments should be made at this time if not already in process.

Foster care history — History gathering for children in foster care is a challenging and time-consuming, labor-intensive task. In addition to the usual components of health history, information for a child in foster care should include information about the child's reason(s) for placement, trauma history, legal status, and the names and roles of the child welfare workers who are responsible for the child (eg, foster parents, caseworker, law guardian). Information should be gathered from as many sources as possible (previous health care providers, caseworkers, foster parents, natural parents, other relatives, schools, childcare centers, etc) to obtain medical, family, social, behavioral, and educational histories that are as complete as possible. Information about a child's strengths, talents, and interests should also be included. Information is often not available at entry to care and can take weeks to months to obtain.

Child welfare is ultimately responsible for obtaining and sharing health information since the child is in their care and custody. However, clinicians may be able to assist by providing a form for the caseworker to fill out or assisting with information gathering. Details of the child's current foster care history and any past out-of-home placements are important. Pediatric providers are often the gatekeepers to other needed care and often find themselves in the role of interpreting information for caregivers and children. Thus, the following information is helpful for health providers:

The age and circumstances under which the child entered the foster care system, including the psychosocial history (maltreatment history, family composition, family disruption, domestic violence exposure, family mental health history, family involvement with criminal justice, etc). In an observational study, an increase in number of foster placements and separation from siblings was associated with greater mental health difficulties while in foster care [79].

The number of placements and the circumstances/reasons for the placement changes, including kinship placements, some of which may have occurred prior to foster care.

The child's feelings about being in foster care.

Observations from available caregivers about the child's adjustment to the current placement.

The frequency and nature of contact or visitation with biologic parents and siblings, including supervision, if any, at visits.

The composition of the foster family (adults in the home; children in the home whether birth, adopted, or in foster care), particularly whether the child's biologic siblings (if they have any) are with them in this foster family.

How other children in foster care fared in this foster family.

The foster parents' attitudes and beliefs regarding discipline and parenting.

How the foster parent approaches integrating children in foster care into their family.

The requirements of any potential reunification plan.

The current permanency plan goal(s) (ie, reunification, placement with a relative/kinship caregiver, adoption, emancipation, placement change). To minimize the length of time in foster care, child welfare often has two concurrent goals at the time of placement: reunification and alternative permanency planning.

Whether the child is free for adoption or adoption is in process.

Examination — Children placed in foster care should have a comprehensive physical examination that remains sensitive to their prior trauma history to assess their health status. Particular attention should be paid to growth parameters, skin findings, vision, hearing, dental, musculoskeletal, and neurologic health. Young children should be screened for developmental problems. Adolescents should be assessed for sexual maturation and fitness for sports participation. (See "Normal puberty" and "Sports participation in children and adolescents: The preparticipation physical evaluation".)

Given the burden of childhood trauma, particularly maltreatment, among children in foster care, the clinician must weigh the benefits of obtaining a comprehensive physical examination against the potential trauma to the child. Additional considerations include the child's level of comfort, cooperation, and willingness to engage in the examination. Although every part of the child's skin should be viewed during the course of the examination, the examination does not require fully undressing the child, which may be traumatic. Whenever possible, when there is suspected sexual abuse, genital examination should be performed by a trained forensic clinician.

Growth – Assessment of growth is an important component of the physical examination for children in foster care. They may have short stature, under-nutrition, or obesity. Poor weight gain may be the first sign of poor care in a foster home.

Short stature is twice as common among children entering foster care as it is in the general population [7,8,20,92]. This usually reflects malnutrition, prenatal substance exposure, prenatal intrauterine growth restriction or small for gestation age without postnatal catch-up growth, and/or psychosocial deprivation that preceded placement ("psychosocial short stature") [93,94]. In one cohort study, 47 percent of 45 children (18 months to 6 years) showed significant catch-up growth during their first year in placement [92].

A subgroup of children with psychosocial short stature may have hyperphagic short stature (short stature and growth hormone insufficiency in association with hyperphagia and behavioral symptoms, such as stealing food, gorging and vomiting, and foraging for discarded food) [95]. These children have spontaneous recovery of growth-hormone production when stress is removed or reduced.

Obesity is another form of malnutrition that is seen with increasing frequency at entry into, or emerging shortly after entry into, foster care. (See "Clinical evaluation of the child or adolescent with obesity".)

Skin and musculoskeletal examination – The skin and musculoskeletal system should be examined for signs of recent or old trauma, bruises, scars, deformities, and limitation of function [46]. (See "Physical child abuse: Recognition", section on 'Red flag physical findings'.)

Immunization status — The immunization status of children entering foster care should be determined, if possible. It may be necessary to piece the immunization history together by obtaining medical records from a variety of sources (including state registries, prior providers, and school or day care providers). If the immunization history cannot be documented, the child should be considered susceptible to vaccine-preventable illnesses and immunized appropriately [20]. Most states do not allow foster parents to decline immunizations. For safety reasons, the AAP recommends that children younger than two years of age be placed in homes where members are fully vaccinated. (See "Standard immunizations for children and adolescents: Overview", section on 'Catch-up schedule'.)

Chronic conditions — Close attention should be paid to manifestations of chronic illness (eg, asthma, eczema), which may not have been appropriately cared for before placement in foster care and some of which may flare during times of stress. Anticipatory guidance should be provided to foster parents and caseworkers to address these needs proactively.

Screening

Routine screening — Children in foster care may not have received adequate health maintenance and preventive care before foster care placement. In addition, circumstances before placement may increase the risk of iron deficiency anemia, lead poisoning, infestations, tuberculosis, and other infectious diseases [2]. Routine screening for these and other conditions, including vision and hearing loss, is discussed in detail separately. (See "Screening tests in children and adolescents", section on 'Common screening tests in pediatrics'.)

A few conditions deserve special emphasis in the foster care population:

Development – Referral for a full developmental evaluation is preferred to screening for this high-risk population. For children age ≤3 years in the United States, Early Intervention (EI) is the appropriate evaluation resource. Under federal law, children with documented child neglect or abuse are automatically eligible for an EI evaluation [96]. For preschool-aged children, school districts have the responsibility to conduct an educational assessment and develop an individualized education plan (IEP) or 504 plan for children with identified needs who meet eligibility criteria. Referral is not necessary for those children who already have an IEP or 504 plan, but providers may want to obtain a copy and monitor its implementation. (See "Definitions of specific learning disorder and laws pertaining to learning disorders in the United States".)

Screening is reasonable in communities lacking the resources to conduct full evaluations for every child in foster care. Every preventive health care visit for children younger than five to six years of age is an opportunity to assess development using a validated screener and ensure that children receive further evaluation as indicated. Children who have passed previous developmental screenings may fall off their trajectories as developmental tasks become more complex or because of the impact of accumulating stressors. Developmental screening may help the provider to determine which children do not need further assessment versus those who require monitoring or referral. The accuracy of information depends upon how familiar the foster caregiver is with the child. Screening with a validated instrument increases the detection of developmental delay [97]. (See "Developmental-behavioral surveillance and screening in primary care", section on 'Approach to screening'.)

Developmental assessments are critical while children are in protective custody. One study in a foster care clinic found that 77 percent of young children entering foster care were not receiving developmental services and 75 percent failed developmental screening [98]. Among those potentially eligible for services, 60 percent had not been referred for development services.

Mental health and trauma – Mental health and trauma are the most significant health concerns for children and adolescents in foster care. (See 'Mental health' below and 'Exposure to maltreatment' below.)

Hearing, speech, and vision – Hearing, speech, and vision screenings may be helpful in identifying toddlers and preschool children who need additional services [99]. (See "Hearing loss in children: Screening and evaluation" and "Vision screening and assessment in infants and children".)

Education – Clinicians should ask about school problems and school performance, and request an educational evaluation if school academic or behavioral performance is marginal or below grade level. Child welfare is mandated by law to maintain children in their school of origin whenever possible, even if they have to provide transportation to do so [100]. However, extraordinary travel requirements may qualify as a compelling reason for a child to change schools upon entry to foster care. Communication between the foster parents, school personnel, the caseworker, and the clinician are essential to the identification and amelioration of school issues. School personnel may need help in understanding the child's behavioral issues in the context of their history of trauma and loss. The comprehensive evaluation and management of children with developmental and educational disorders requires an organized system of follow-up and consultation [51].

Many children in foster care have symptoms of inattention, impulsivity and hyperactivity, and the pediatric provider may receive requests for pharmacologic treatment of presumed attention deficit hyperactivity disorder (ADHD). However, in a child with a history of trauma, ADHD symptoms require a full mental health assessment before considering initiation pharmacologic treatment of ADHD. Although the symptoms of ADHD or posttraumatic stress disorder (PTSD) may be due to complex childhood trauma, a diagnosis of ADHD or PTSD may be helpful in obtaining accommodations in education settings or receipt of services within school and social service systems (since childhood trauma and developmental trauma disorder do not have a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition classification or a diagnostic code). (See "Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis", section on 'Differential diagnosis' and "Definitions of specific learning disorder and laws pertaining to learning disorders in the United States", section on 'Laws affecting the education of students with disabilities'.)

Dental health – Children older than 12 months should be referred to a dentist for an initial dental assessment, and children should receive routine dental care while in foster care. Application of fluoride varnish in the pediatric medical home is advised if dental care is delayed. (See "Preventive dental care and counseling for infants and young children".)

Infectious diseases — Maternal lifestyles may increase the risk of vertically transmitted infections such as syphilis, herpes simplex virus, HIV, and hepatitis B and C among children entering foster care. Adolescents may be at risk for these infections because of unsafe sexual practices, tattoos, body piercing, or needle-sharing.

The guidelines for testing children and adolescents in foster care for these conditions vary from state to state. However, we suggest that children and adolescents entering foster care be tested for hepatitis C, syphilis, and HIV. We screen children for hepatitis B if they do not have documentation of complete immunization. Tuberculosis screening may be warranted for children with increased risk, including exposure to an infected individual or an individual at high risk whose status is unknown. (See "Hepatitis B virus immunization in infants, children, and adolescents" and "Clinical manifestations and diagnosis of hepatitis B virus infection in children and adolescents", section on 'Screening tests' and "Tuberculosis infection (latent tuberculosis) in children", section on 'Whom to test'.)

Clinicians may adapt our screening recommendations to reflect the prevalence of infectious diseases in their states and/or communities [101]. Individual risk should be assessed when community prevalence rates are so low that universal screening is not recommended. As an example, in an observational study of children entering foster care from one county, <1 percent of children entering foster care tested positive for hepatitis B, hepatitis C, syphilis, and tuberculosis, and none tested positive for HIV [102].

Routine screening of urine for sexually transmitted infections is recommended for adolescents beginning at age 11 years. Urine pregnancy screening is also recommended for all adolescent females in foster care beginning at age 11 to 12 years. In an observational study of children entering foster care from one county, 7 percent of adolescents tested positive for Chlamydia [102].

Pediatric providers should become familiar with the particular emancipated minor laws and regulations governing HIV risk assessment, screening, and information sharing for the foster care population in their state [103]. As a general rule, birth parents retain the right to consent for HIV testing unless the child is eligible for adoption or parental rights have been terminated [103]. However, adolescents in the foster care system may consent to HIV testing unless they are cognitively impaired. (See "Consent in adolescent health care", section on 'Sexually transmitted infections'.)

Refugee minors may enter foster care because they are unaccompanied by an adult or for reasons of child abuse and neglect. Most come from countries in which parasitic, bacterial, or viral infections are common, so the initial screening should include: hepatitis B and C, rapid plasma reagin, HIV, complete blood count (CBC), and screening for tuberculosis. If the CBC has a higher than usual percentage of eosinophils or absolute eosinophil count, screening for parasitic diseases endemic to the country of origin is recommended. Screening for tuberculosis is discussed separately. (See "Tuberculosis infection (latent tuberculosis) in children", section on 'Whom to test'.)

Refugee minors with abdominal pain or other symptoms suggestive of Helicobacter pylori infection may benefit from referral to gastroenterology for assessment. (See "Indications and diagnostic tests for Helicobacter pylori infection in adults".)

Mental health — Because of their significant trauma histories and losses, mental health is the most significant health concern for children and adolescents in foster care. The clinician should also assess for trauma symptoms such as dysregulation of sleep, elimination (ie, voiding and stooling), and eating, or problems with emotions and behavior.

Screening for mental health problems with a validated mental health screening instrument (eg, the Ages and Stages Questionnaire: Social-Emotional, second edition for children <6 years; the Child Behavior Checklist; the Strengths and Difficulties Questionnaire, etc) should be performed during the comprehensive assessment. The use of validated screening instruments facilitates detection of social-emotional problems and is vital to capturing the "ripple effects of trauma" [104,105]. Recommended screening tools are available through the AAP's Mental Health Initiatives. Trauma screening is a challenge in most primary care settings because trauma screens are proprietary and often take longer to administer than other mental health screens; however, it can be useful, particularly if providers with trauma-informed mental health expertise are available on-site. The Pediatric Traumatic Stress Screen is a brief, well-validated screener evaluated in primary care settings. It focuses on the intrusive, avoidance, and activation symptoms that children may display after experiencing trauma. It is available for free in English and Spanish versions and has a brief training program available [106]. (See 'Complex childhood trauma and toxic stress' above.)

Potential problems identified on screening, especially the presence of trauma symptoms, a high trauma burden, or concerns on the part of caregivers, caseworkers, teachers, and/or the clinician indicate the child needs referral for a full mental health evaluation if one is not already in process [1,21,22,30,32,49,107].

Exposure to maltreatment — Child abuse and neglect is reported rarely in foster homes but does occur [69]. This possibility should be considered whenever a child is losing or failing to gain appropriate weight in a foster home, if the child's behavior deteriorates, or the child appears depressed or hypervigilant in the presence of the foster parent. Even though most behavioral problems, including hypervigilance, are the result of prior trauma, the clinician must remain alert to the possibility of maltreatment in the current placement. It is important to see the verbal child privately, for at least a few minutes, to ensure that they feel supported and cared for in the foster care home. (See "Poor weight gain in children older than two years in resource-abundant settings", section on 'Limited or inappropriate intake' and "Poor weight gain in children younger than two years in resource-abundant settings: Etiology and evaluation", section on 'Causes'.)

Children in foster care also should be screened for exposure to violence. (See "Intimate partner violence: Childhood exposure", section on 'The process of asking about caregiver intimate partner violence'.)

Helping Foster and Adoptive Families Cope With Trauma, published by the AAP, is a guide to help clinicians identify and support traumatized children and their families.

Education and support — Anticipatory guidance, particularly related to the effects of trauma on the developing brain, supporting the traumatized child, managing chronic illness and behavioral concerns, may help to avoid unnecessary visits to the emergency department [37,91]. Behavior-shaping techniques should focus on spending "time in" with the child in play, reading, or other jointly enjoyable activities, using positive words and instructions, distraction techniques, teachable moments, providing reassurance, and rewarding positive behaviors. Foster parents should be counseled in using coregulation techniques to help children when they become distressed (remaining calm and present at eye level with child, using a reassuring tone of voice and gentle touch if tolerated) [15,108]. Health care professionals can advise foster parents that while children may experience emotional difficulties during the transitional period into foster care, providing consistency, predictable routines, and emotional support in the foster home environment promotes adjustment. School-age children and adolescents need extensive education about healthy relationships, conflicted loyalties, reproductive health, safe sexual practices, handling their emotions, identity formation, and the benefits of mental health therapy. Participation in structured group activities and connecting children with adult mentors may improve social relationships and mental health [109]. There is strong evidence that individual and group trauma-informed cognitive-behavioral therapy can help to ameliorate psychological symptoms of children and adolescents who have experienced early childhood trauma [110]. Involvement in social and extracurricular activities have been shown to decrease the negative consequences of trauma [111,112]. Foster parents may need additional resources of funding and/or transportation to support these positive experiences [113].

Information about effective interventions and parenting the traumatized child is available through the National Child Traumatic Stress Network and the California Evidence-Based Clearinghouse for Child Welfare.

FOLLOW-UP VISIT — The follow-up visit is the final visit in the admission health series. It should occur 30 to 60 days after the comprehensive assessment. The goals of the follow-up visit are:

Review of any newly obtained health history

Assessment of adjustment to foster care and life in the foster home

Assessment of how visitation is going

Monitoring for abuse and neglect

Provision of support and guidance to the foster parent regarding behavior, discipline, and nurturing the child through the transition process

Ongoing monitoring of health, mental health, and development, and education

Continued catch up of immunizations if needed

Follow-up care for chronic medical issues

Ongoing parenting education and guidance

Questions that help to assess adjustment to foster care include [114]:

For the foster parent:

"How do you think your child is doing? How do they fit into your family?"

"Do they have any behaviors that you are worried about?"

"What has it been like for you and others in your home since the child moved in?"

"Have there been any other significant changes in your family or in the child's family?"

"How are they adjusting to visitation?"

For the child, without the foster caregiver present (depending upon the child's maturity and ability to communicate):

"What is it like for you living in your new home?"

"Do you have family members from whom you have been separated? Who are they and what is your contact with them?"

"What do you like most? What do you like least?"

"How do you get along with the people in your new home?"

"What would you like to change?"

"Do you feel supported and cared for in your new home?"

In addition to measuring growth parameters and a brief physical examination, the clinician should review the results of the mental health evaluation and developmental or educational evaluations with the foster parent and birth parent (if available). Adolescents in foster care may be included in these discussions. Standardized assessment tools can be used at follow-up visits to assess for the emergence of new-onset behavioral or developmental difficulties (see "Developmental-behavioral surveillance and screening in primary care", section on 'Approach to screening'). The clinician should update the health care plan, schedule the next health visit, and communicate their recommendations to the child's caseworker.

RECOMMENDED HEALTH SURVEILLANCE SCHEDULE — Children and adolescents in foster care have a high rate of health and mental health and developmental problems (table 1), may live in circumstances that do not meet their needs for stability and permanency, and are exposed to multiple stressors and transitions that threaten their health and well-being [46].

Thus, the AAP recommends that children in foster care have more frequent health care visits to monitor their physical, emotional, developmental, and mental health [46]:

Infants should be seen monthly until age six months, particularly if born prematurely

Toddlers should be seen every three months from 6 to 24 months of age

Every child in foster care should be seen at least every six months between ages 24 months and 21 years to monitor health, mental health, behavioral, and developmental/educational progress, and to provide appropriate support and education

A major challenge for health providers is receiving financial payment for adhering to this proactive health visit schedule.

During prevention and oversight health care visits, the clinician should:

Provide ongoing support and guidance to foster parents regarding positive parenting strategies, discipline, and managing behaviors in the context of a child's trauma history and developmental stage.

Screen for emerging mental health, developmental, and educational issues. If the child younger than six years is not involved in ongoing developmental services, the clinician should continue to administer an age-appropriate validated developmental screening instrument to periodically screen for emerging developmental problems. The maximum recommended interval between screenings is six months. (See "Developmental-behavioral surveillance and screening in primary care", section on 'Approach to screening'.)

If the child is not involved in ongoing mental health services, the clinician should address mental health, emotional, and behavioral issues at the time of each preventive/monitoring health visit or whenever the foster parent, birth parent, caseworker, teacher, or other professional involved with the child has a concern. Referral to a pediatric mental health professional is indicated when concerns are raised if integrated mental health services are not available in the medical home.

Remain alert to signs of abuse and neglect. (See "Physical child abuse: Recognition" and "Evaluation of sexual abuse in children and adolescents" and "Child neglect: Evaluation and management".)

Work with the foster caregiver and caseworker to ensure that all of the child's health needs are appropriately addressed. This may involve preparing information for court.

Focus on the child's assets and strengths. For the late adolescent or young adult, this includes a focus on preparing for independent living.

Promote involvement in normalizing activities and healthy lifestyles.

Ensure that adolescents are screened for sexually transmitted infections, pregnancy, and high-risk behaviors. (See "Guidelines for adolescent preventive services", section on 'Screening'.)

Include anticipatory guidance about foster care issues: supporting the child around visitation, permanency planning, and court-related issues; dealing with conflict between birth and foster parents; and managing behavior in a child with a history of complex trauma. Caregivers and health care professionals may seek additional resources to address these issues from professional organizations (table 2).

PRIMARY CARE PROVIDER'S ROLE — The primary care provider has an opportunity to be the health care provider, health educator, health coordinator, and health advocate for the child in foster care. The provider may be one of the few sources of stability, support, and advice in the child's otherwise chaotic life.

The health and development of children in foster care may improve during stable placement and can be enhanced if coordinated, comprehensive, specialized care is provided [20,115,116]. Pediatric practices that provide medical care for children in foster care should be organized to accommodate the special needs of these children.

Below are some ways that the foster care-friendly, trauma-informed pediatric office can optimize primary care visits for children in foster care:

The appointment length should be modified to permit time for comprehensive evaluation and patient/caregiver education, particularly regarding trauma-informed anticipatory guidance around foster-care-related issues, behavior management, the management of chronic illness, and adolescent issues.

The child's physical, emotional, and educational problems should be addressed promptly and in the context of their life circumstances and trauma history to optimize the child's future development.

Mental health services should be provided by a pediatric mental health professional with expertise in complex childhood trauma whenever possible.

Arrangements should be made for children who need subspecialty care to be seen promptly, and the recommendations of the subspecialist integrated into the primary provider's care plan and the caseworker's permanency plan.

Appropriate medical assessment or intervention should not be delayed pending planned reunification with birth parents, because these plans are often disrupted or delayed.

Careful documentation is important since health records may be requested by subsequent providers, child welfare agencies, or the court.

An abbreviated health record ("health passport") that is updated (particularly regarding health problems, allergies, immunizations, growth curves, and current medications) at each health care encounter should be provided to the foster parent in either electronic or paper format. Adolescents should have access to the passport, which should also be available or transferred to the birth, adoptive, or next foster parent(s) at the time of transition. Youth who age out of foster care should receive or have access to a copy of their health passport. A secure but accessible web-based health passport is ideal, but passports can be paper or electronic.

The clinician should be prepared to advocate on behalf of the child in situations of conflict with or between social service agencies, schools, the birth parents, and the courts. Clinicians may occasionally need to discuss the child's care with the Guardian ad Litem (law guardian) to assist in decision-making regarding the child or adolescent [117]. (See "Epidemiology of foster care placement and overview of the foster care system in the United States", section on 'Foster care personnel'.)

The clinician should provide education to the caseworker and other adults who share responsibility for the child's welfare to ensure that health decisions are consistently made in the child's best interest.

Clinicians are encouraged to learn about the health needs of youth aging out of the foster care system and to be aware of state (or other local) programs to provide health care coverage for these youth [118]. Resources are available through the American Academy of Pediatrics. As of January 1, 2014, youth who age out of foster care can retain their Medicaid coverage until age 26 years.

In addition, pediatric health care providers may wish to participate in aspects of foster care at the community level. They may help to identify and recruit foster parents, participate in continuing education programs for the staff of child welfare agencies or foster parents, share in the development of policies and procedures for health care for children in foster care, or become a member of a citizens' review board that monitors the planning of agencies on behalf of the children in their care. Pediatric health providers may also wish to work at the state level through their local AAP chapter. Since 2008, states have been required to engage pediatricians in the development of health care oversight systems for children in foster care [100].

SUMMARY

Health needs

Children in foster care are a uniquely vulnerable population, with an increased prevalence of chronic medical, developmental, and mental health problems (table 1). (See 'Overview' above.)

Complex childhood trauma underlies many of the health problems affecting children and adolescents in foster care. Their health problems may be compounded by the trauma of removal and separation from their parents/caregivers and the ongoing uncertainty of living in foster care. (See 'Complex childhood trauma and toxic stress' above.)

Health care provision – Health care for children and adolescents in the foster care system includes information gathering, an admission health series consisting of at least three visits, developmental or educational evaluation, mental health evaluation, and a proactive preventive/monitoring health care schedule. (See 'Health care provision' above.)

Initial screening – The initial health screening should occur within 72 hours of removal from the birth parent. The objectives of this encounter are assessment for:

Abuse and/or neglect

Contagious diseases

Acute mental health issues

Acute or chronic health needs requiring immediate attention

In addition, this is an opportunity to provide guidance regarding the empathetic management of behaviors related to prior trauma. (See 'Initial screening' above.)

Comprehensive health assessment – The comprehensive health assessment should occur within one month of placement. The goals of the comprehensive assessment are to identify and formulate a management plan for each health problem and ensure that the plan is communicated to the child welfare caseworker and foster parent. Referral for mental health, developmental, educational, and dental assessments should be made if not already in process. (See 'Comprehensive health assessment' above.)

Follow-up visit – The follow-up visit should occur 30 to 60 days after the comprehensive assessment. The follow-up visit provides an opportunity to review newly obtained health history, including the results of the mental health and developmental (or educational) evaluations, assess adjustment to foster care and visitation, monitor for abuse and neglect, and provide support and guidance to the foster parent and child. (See 'Follow-up visit' above.)

Recommended surveillance schedule – Children in foster care should receive preventive health services according to the American Academy of Pediatrics' schedule for children in foster care. Additional monitoring visits are suggested according to the following schedule: monthly until age six months; every three months from age 6 to 24 months; and every six months from 24 months to 21 years. (See 'Recommended health surveillance schedule' above.)

Role of the primary care provider – Pediatric practices providing medical care for children in foster care should be trauma-informed and organized to accommodate the special needs of these children. (See 'Primary care provider's role' above.)

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Topic 588 Version 40.0

References

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