HEALTH CARE NEEDS
OF CHILDREN AND YOUTH
IN THE FOSTER CARE SYSTEM
- TRAINEE’S GUIDE -
Trainee Desk Guides
CONTENTS
TOPIC:
PAGE:
Health Vulnerabilities of Children in Foster Care
2
Health Defined
9
Health and Education Passport – Important Medical History
10
CHDP: Child Health and Disability Prevention Program
12
Confidentiality
13
Chronic Care for Children with Special Medical Needs
14
Common Core | Health Care Needs of Children and Youth in the Child Welfare System:
Trainee’s Guide | Version 1.0, July 2008
Health Vulnerabilities of Children in Foster Care
Children in foster care require special attention to their medical needs. Children in
foster care experience more special health care needs than other children1 and are at
risk for chronic medical conditions such as asthma, diabetes, and HIV. Children in foster
care are also affected by other serious medical problems associated with poverty,
prematurity, physical abuse trauma, and accidental trauma. Adolescent youth have
specific medical risks associated with the developmental changes they are experiencing.
Social workers should be aware of the symptoms of these conditions and the impact the
conditions can have on the child’s overall health.
ASTHMA
A study of San Francisco foster care children receiving their first CHDP exams showed
asthma as the leading serious chronic condition.2
Asthma symptoms include:3
 coughing, especially at night
 wheezing
 shortness of breath
 chest tightness, pain, or pressure
TUBERCULOSIS
A study of children in San Francisco showed significantly increased rates of positive
tuberculosis skin tests for children entering care.4
A child with a positive skin test for tuberculosis does not mean the child has tuberculosis
disease. Only 10% of people who test positive will ever develop symptoms. Because
symptoms may not be noticed until the disease is quite advanced, children must be
tested when they enter foster care and the treatment plan is based on the results of the
test and the child’s medical history.
Tuberculosis symptoms include:5
1
Ringeisen, H., Casanueva, C., Urato, M., Cross, T. (2008). Special health care Needs Among Children in the Child
Welfare System. Pediatrics, 122(1), 232-241.
2 Takayama, J.I., Wolfe, E., Coulter, K.P. (1998) Relationship Between Reason for Placement and Medical Findings
Among Children in Foster Care. Pediatrics, 101(2), 201-207.
3 Source: Retrieved on November 4, 2008 from http://www.webmd.com/asthma/guide/asthma-symptoms
4 Takayama, J.I., Wolfe, E., Coulter, K.P. (1998) Relationship Between Reason for Placement and Medical Findings
Among Children in Foster Care. Pediatrics, 101(2), 201-207.
5 Source: Retrieved on January 6, 2009 from http://www.emedicinehealth.com/tuberculosis/page3_em.htm
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weight loss
lack of energy
poor appetite
fever,
cough
night sweats
DIABETES
There is a growing number of children in foster care with diabetes, in part related to the
obesity epidemic (also seen more frequently in minority children).
Diabetes symptoms include:6
 excessive thirst and appetite
 increased urination (sometimes as often as every hour)
 unusual weight loss or gain
 fatigue
 nausea, perhaps vomiting
 blurred vision
 in women, frequent vaginal infections
 in men and women, yeast infections
 dry mouth
 slow-healing sores or cuts
 itching skin, especially in the groin or vaginal area
HIV/AIDS
HIV is increasingly less common in pediatric populations because of the success of
prenatal screening which drastically lowers the chance of prenatal transmission. Some
counties may still see the rare newborn or infant with HIV (especially when prenatal
care is lacking) or more commonly see HIV infection in teens with at-risk behavior.
Following initial HIV infection, there might not be any symptoms. The progression of
disease varies widely among individuals. The symptom free state may last from a few
months to more than 10 years. Once the immune system weakens, a person infected
with HIV may develop symptoms. AIDS is the most advanced stage of HIV infection. The
definition of AIDS includes all HIV-infected people who have fewer than 200 CD4+ cells
per micro-liter of blood. Most of these conditions experienced by people with AIDS are
infections caused by bacteria, viruses, fungi, parasites, and other organisms. Nearly
every organ system is affected.
6
Source: Retrieved on November 4, 2008 from http://diabetes.webmd.com/guide/understanding-diabetessymptoms
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HIV/Aids symptoms include:7
 lack of energy
 persistent or frequent yeast infections
 persistent skin rashes or flaky skin
 short-term memory loss
 mouth, genital, or anal sores from herpes infections
 cough and shortness of breath
 seizures and lack of coordination
 difficult or painful swallowing
 mental symptoms such as confusion and forgetfulness
 severe and persistent diarrhea
 fever
 vision loss
 nausea, abdominal cramps, and vomiting
 weight loss and extreme fatigue
 severe headaches with neck stiffness
 coma
PREMATURITY
Premature infants entering foster care can have numerous health issues needing close
monitoring.
Problems associated with prematurity include:8
 feeding problems
 lung disease
 temperature regulation
 cerebral palsy
 seizures
 retinopathy of prematurity
 blindness
 hearing loss
 developmental delay
Special care needs for premature infants include:9
 premature infants sleep shorter periods of time and have shorter periods of
being awake
 premature infants require more frequent feeding
 premature infants have decreased immunity and must be kept away from family
members and friends who might be ill
7
Source: Retrieved on November 4, 2008 from http://www.webmd.com/hiv-aids/guide/hiv-symptoms
Source: Retrieved on November 4, 2008 from http://children.webmd.com/tc/premature-infant-overview
9 Source: Retrieved on November 4, 2008 from http://children.webmd.com/tc/premature-infant-overview
8
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premature infants have an increased rate of SIDS and should always sleep on
their backs
SHAKEN BABY SYNDROME
Traumatic brain injury resulting from Shaken Baby Syndrome or severe abuse typically
leads to devastating results. Severe developmental delay, cerebral palsy and seizures
are common. Shaking, throwing a child, or slamming the child against an object causes
uncontrollable forward, backward, and twisting head movement. Brain tissue, blood
vessels, and nerves tear. The child’s skull can hit the brain with force, causing brain
tissue to bleed and as well. Children with signs of acute injury from shaken baby
syndrome should receive immediate medical attention. Children who have a brain
injury from shaken baby syndrome require ongoing medical attention and treatment.
Signs of acute injury from shaken baby syndrome include:10
 lethargy
 irritability
 vomiting
 poor sucking or swallowing
 decreased appetite
 lack of smiling or socialization
 rigidity
 seizures
 difficulty breathing
 altered consciousness
 unequal pupil size
 inability to lift the head
 inability to focus the eyes or track movement
Chronis problems associated with shaken baby syndrome include:11
 partial or total blindness
 hearing loss
 seizures
 developmental delays
 impaired intellect
 speech and learning difficulties
 problems with memory and attention
 severe mental retardation
 cerebral palsy
10
11
Source: Retrieved on December 8, 2008 from http://kidshealth.org/parent/medical/brain/shaken.html
Source: Retrieved on December 8, 2008 from http://kidshealth.org/parent/medical/brain/shaken.html
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If shaken baby syndrome is suspected, doctors may look for:12
 hemorrhages in the retinas of the eyes
 skull fractures
 swelling in the brain
 subdural hematomas (blood collections pressing on the surface of the brain)
 rib and long bone (bones in the arms and legs) fractures
 bruises around the head, neck, or chest
Health Risks of Younger Children13
Injury
Among children ages 1-4 years, unintentional injuries are the leading cause of death;
followed by birth defects, homicide, and cancer. Similarly, among children ages 5-14
years, unintentional injuries remain the major cause of mortality; followed by cancer,
birth defects, and homicide. Motor vehicle injuries are the most common type of fatal
injury. In 2002, 40% of child passengers ages 1-4 years who died in motor vehicle
crashes were unrestrained. 45% of children ages 5-9 and 54% of children ages 10-14
who died in motor vehicle crashes were not wearing a seatbelt or other restraint.
Obesity
An estimated 17% (12.5 million) children and adolescents ages 2-19 years are
overweight. Children who watch more than three hours of television per day are 50%
more likely to be obese than kids who watch fewer than two hours. According to the
CDC, 6% of overweight children between the ages of 5-10 years of age already have at
least one risk factor for heart disease, including elevated blood cholesterol, blood
pressure, or increased insulin levels. These are the factors that lead to hypertension,
diabetes, and atherosclerosis.
Immunization
In 2005, 17.6% of children ages 19-35 months had not received the recommended
combined series of vaccines.
12
13
Source: Retrieved on December 8, 2008 from http://kidshealth.org/parent/medical/brain/shaken.html
Source of statistics: American Academy of Pediatrics
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Health Risks of Adolescents14
Injury
Injuries from motor vehicles and firearms are the leading mechanisms of injury death
among adolescents.
Risk behaviors
According to the 2005 Centers for Disease Control and Prevention (CDC) Youth Risk
Behavior Surveillance System, a survey of high school students nationwide, during the
30 days preceding the survey:
 43% of students had recently drunk alcohol and 26% reported episodes of heavy
drinking.
 5.4% of students had recently carried a gun and 6.5% of students carried the
weapon onto school property.
 6% of students missed one or more days of school because of safety concerns
Sexual Activity
In 2005, 46.8% of high school students reported having sexual intercourse during their
lifetime, and 6.2% reported first sexual intercourse before age 13 years. Of those
sexually active, 62.8% reported condom use during last sexual intercourse.
Smoking
In 2005, 54.3% of high school students reported they had ever tried cigarette smoking
and 9.4% of students nationwide report they are current frequent users of tobacco.
What can social workers do to reduce risk?
A growing body of research from around the world identifies key factors associated with
less involvement among young people in a wide range of negative health and social
outcomes. Social workers can improve outcomes for children and youth in foster care by
providing children and youth with opportunities to experience those key factors. They
are:15
14
Source of statistics: American Academy of Pediatrics
15
Adapted from the International Youth Foundation’s 5 Cs, retrieved on January 13, 2009 from
http://www.iyfnet.org/uploads/what_works_in_youth_par.pdf
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Confidence in areas that improve the quality of young people’s lives, such as
literacy, employability, and interpersonal, vocational, and academic skills that
allow individuals to contribute to their communities.
Connection of youths to persons in the community who provide mentoring,
tutoring, leadership, and community service opportunities.
Character through values such as individual responsibility, honesty, community
service, responsible decision making, and integrity, and relationships that give
meaning and direction to young people.
Confidence-building experiences that give youth hope and self-esteem through
success in setting and meeting goals.
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Health Defined
What is health?
As defined by the World Health Organization, health is a state of complete physical,
mental, and social well-being and not merely the absence of disease or infirmity. This
holistic definition of health includes physical health, emotional well-being, social/familial
relationships and spiritual/cultural connection.
Key points for social workers to remember:
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One’s health and illness is always viewed and experienced within a social,
psychological and cultural basis. Useful strategies for solving complex medical
issues must incorporate the cultural and psychological surrounding of the child.
Our approach to the treatment of physical complaints is often influenced by our
own upbringing and our own conceptual models for health and disease. The
social worker must be aware of the filters that are being superimposed on
her/his beliefs and problem solving skills.
A child’s past history and vulnerabilities in foster care and the impact of racial
disparities are critically linked to his/her health status.
Children, like adults, may manifest physical complaints for complex unconscious
psychological reasons. This relationship is often called “psychosomatic” but it is
incorrect to assume this means “not real.” Before assuming it is “in his head,”
make sure there are no hidden medical conditions in need of treatment.
Obtaining a medical history is a critical first step in accepting responsibility for a
child’s welfare.
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Health and Education Passport - Important Medical History
Why is the medical history important?
Fragmentation and loss of medical history creates poor health care. This affects
children in foster care as they are more likely to have missing medical history
information and they are more likely to have special health care needs conditions. 16
Children in foster care also have a high incidence of developmental delays. Medical
professionals report treating foster children for anemia, neurological, respiratory,
digestive and dermatologic problems.17 In order to provide the best care for children
experiencing these conditions, medical professionals must have information about the
progress of the condition over time and the previous treatment of the condition.
Children often arrive in foster placement under-immunized and with no immunization
records. If the records are not found prior to the initial medical appointment, the child
will often be re-immunized. Although this is not dangerous, from the child’s perspective
it is quite painful and traumatic to have multiple injections at multiple medical visits
shortly after placement. The more the social worker can do to help minimize the
trauma to a child in placement, the greater the likelihood of enhancing the child’s well
being and adjustment.
How can a social worker gather medical history information?
The best way to gather medical history information is to access medical records from
the child’s primary care physician. At the time of removal, social workers must inquire
about the child’s medical needs to ensure the child continues any medication he or she
is taking and continues any other ongoing treatment. If possible, the social worker
should ask the birth parent to sign a release of medical records. Soon after removal, the
social worker will attempt to gather more thorough medical information during
interviews with the child and family. Family members can provide contact information
for medical/dental providers (names, addresses, phone numbers) and relevant family
medical history (including parental psychiatric history or drug abuse).
Informants of a child’s medical history can include:
 Parents and other family who have helped raise the child can Previous foster
parents
16
Ringeisen, H., Casanueva, C., Urato, M., Cross, T. (2008). Special health care Needs Among Children in the Child
Welfare System. Pediatrics, 122(1), 232-241.
17 Source: Retrieved January 6, 2009 fromhttp://www.ucdmc.ucdavis.edu/caare/medicalservices/fosterhealth.html
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Prior health care providers, especially any that provided services recently or for a
period of time
Verbal medical history from parent
Immunization cards provided by parent or other caregiver
Sources of the medical records are:
 Any facility/medical provider that has treated the child in the past, including
primary care, hospitals, school nurses, and other health agencies
 Case file if child has been in the system
 The CWS/CMS Health Passport
How can the Health and Education Passport (HEP) help children receive better medical
care?
The Health and Education Passport is a document within the CWS/CMS reflecting the
health and education data collected and recorded. The Passport document is generated
by CWS/CMS for use by social workers, foster care providers, and medical providers to
improve knowledge of the child’s health history and to promote continuity in service
delivery. The Passport should include immunizations and medications, demographic
information on service providers, diagnosed medical and psychosocial conditions, and
education information.
The HEP serves three critical functions:
 it provides a written information to caregivers and should be given to foster
parents (at time of placement and after every update) and to parents (at the
time of reunification)
 it provides written information to medical clinicians new to the child
 it serves as an important medical history record storing key facts in an electronic
file that can be accessed by any county in the state
Key items to put in HEP:
 Names, addresses and telephone numbers of all medical providers and agencies
(CCS, Regional Center, speech therapist, dentists, medical specialists, etc.)
 Immunization history
 Birth history
 List of major medical conditions that may need follow up
 List of medications, including dosages and prescribing doctor
 List of allergies
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CHDP: Child Health and Disability Prevention Program
The Child Health and Disability Prevention Program is a preventive program that delivers
health assessments and services to low income children and youth in California.18
Children in foster care are eligible for medical screening through the CHDP program and
are required to have a complete physical (CHDP) exam within 30 days of placement.
CHDP Exam Requirements19
 medical history including dental, nutritional, developmental/behavioral,
tuberculosis exposure, immunization history, medication history, history of
sexual activity, and history of tobacco use
 physical exam including
o dental exam
o nutritional assessment
o developmental/behavioral assessment
o anticipatory guidance
o tobacco assessments
o a pelvic exam is administered for girls over 13 years
o head, length, and weight measurements are required for children up to
23 months
o height, weight, and blood pressure are required for children over 2 years
o sensory screenings including clinical observation and non-audiometric
tests for children under 2 years and additional visual acuity and
audiometric tests for children over 3 years
o tuberculosis exposure and risk assessment
o sexually transmitted disease screenings are required for specific age
groups
o laboratory tests are to be completed when health history and/or physical
examination warrants them
o immunizations are administered as necessary to make status current.
18
19
Source: Retrieved December 24, 2008 from http://www.dhcs.ca.gov/services/chdp/Pages/default.aspx
See CHDP Periodicity schedule (Form 101-2) and AAP/ACIP immunization schedule (Appendix E).
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Confidentiality
Some aspects of medical care for foster youth have complicated confidentiality
requirements. Counties have different strategies for protecting confidentiality rights for
youth while also ensuring that youth are safe.
Access to medical record:
Social workers cannot access medical records without a signed release from the birth
parent. The Health Insurance Portability and Accountability Act (HIPAA) can add an extra
barrier to timely receipt of records. HIPAA, a federal standard, provides a number of
patient rights and limits and restricts the release of medical (especially electronic)
information. When encountering obstacles to timely receipt of medical records,
troubleshooting should be done with the help of a social worker supervisor.
Occasionally a court order is required to obtain needed information. This can usually be
averted with consent from the birth parent.
HIV Confidentiality:
HIV status is considered confidential. Each county has specific policies about handling
information related to the HIV status of a person receiving services. Social workers
should consult supervisors regarding how and where to document HIV status.
Special considerations for youth over age 12:
From a medical perspective, youth age 12 and over have the right to consent to
treatment and have the right to confidentiality regarding birth control, pregnancy and
treatment of sexually transmitted diseases (California Family Code 6926 and 6929 (b),
California Health and Safety Code 123110 (a) and 123115 (a)); however, social workers
must sometimes share information with birth parents, foster parents, or the court in
order to keep youth safe. When a social worker has confidential information about a
foster youth over age 12 regarding sexual activity, sexually transmitted disease status,
or substance abuse, the social worker should consult with the youth’s attorney and a
supervisor and/or county counsel before releasing that information or including that
information in court reports.
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Chronic Care for Children with Special Medical Needs
Children in foster care have a higher incidence of special health care needs than other
children.20 They often have multiple complex problems that require additional attention
and vigilance, beyond the need for regular wellness care.
When working with chronically ill children, social workers should attempt to:
1.
identify chronically ill children and track their progress
2.
acquire basic knowledge of any identified medical condition
3.
utilize the public health nurse (PHN) for consultation and information
about specialized services available
4.
utilize supervision for consultation to ensure chronically ill children are
receiving all the services available to them
5.
consult the child’s medical clinicians regarding the child’s condition and
the requirements needed for disease treatment
6.
consider attending some of the child’s medical specialty visits
7.
enter all related information in the HEP to insure proper care for the
chronically ill child, including provider information, diagnoses,
medications, and all agencies involved with care
Children receiving chronic care may require services from a variety of public agencies
and medical professionals including:
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California Children Services (CCS) 21
o CCS is a state program for children with diagnosed diseases or health
problems, which include but are not limited to chronic medical conditions
such as cystic fibrosis, hemophilia, cerebral palsy, heart disease, cancer,
traumatic injuries, and infectious diseases producing ongoing problems
o CCS offers specialty Multi-Therapy Units (MTUs) and access to physical
therapy (PT) and other therapies not provided by MediCal
o CCS provides health care and services for children and youth children up
to 21 years of age such as diagnostic and treatment services, medical
case management, and physical and occupational therapy services
o CCS can connect social workers or parents with doctors and trained
health care providers who know how to care for children with special
health care needs
20
Ringeisen, H., Casanueva, C., Urato, M., Cross, T. (2008). Special health care Needs Among Children in the Child
Welfare System. Pediatrics, 122(1), 232-241.
21 Source: Retrieved November 17, 2008 from http://www.dhcs.ca.gov/SERVICES/CCS/Pages/default.aspx.
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o CCS provides medical therapy services that are delivered at public schools
o Children must be Med-Cal eligible to be eligible for CCS
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22
Regional Centers 22
o California has 21 regional centers with more than 40 offices located
throughout the state
o Regional Centers serve individuals with developmental disabilities and
their families
o A directory of Regional Center can be found at
http://www.dds.ca.gov/RC/RCList.cfm.
o Regional centers provide diagnosis and eligibility assessment at no charge
and help plan, access, coordinate, and monitor needed services and
supports for eligible children and adults
o Case managers or service coordinators develop plans for services and
provide help with obtaining services
o Most services provided via the Regional Center are free regardless of age
or income
o Some of the services and supports provided by the regional centers
include:
 Information and referral
 Assessment and diagnosis
 Counseling
 Lifelong individualized planning and service coordination
 Purchase of necessary services included in the individual program
plan
 Assistance in finding and using community and other resources
 Advocacy for the protection of legal, civil and service rights
 Early intervention services for at risk infants and their families
 Genetic counseling
 Family support
 Placement, and monitoring for 24-hour out-of-home care
 Training and educational opportunities for individuals and families
 Community education about developmental disabilities
Source: Retrieved on November 17, 2008 from http://www.dds.ca.gov/RC/RCSvs.cfm.
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