DEVELOPMENTAL SCREENING AND MONITORING OF CHILDREN IN FOSTER CARE:

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DEVELOPMENTAL SCREENING AND MONITORING OF
CHILDREN IN FOSTER CARE

• Challenges and Strategies

• Megan Tardif Vanessa Lapointe
• Sue Khazaie

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Goals

• Brief Clinical Snapshot of young children in care
  
• Brief overview of findings and recommendations
  from the Fraser Region Developmental Screening
  Project for Young Children in Foster Care.
• Review of issues that arise when considering
  systematic developmental screening and monitoring
  of children in foster care, such as selecting an
  appropriate screening measure deciding how this
  measure should be administered
• Overview of models for implementation that are
  presented in the related literature with links
  drawn to national, provincial and local efforts.
• Participants' discussion about the challenges,
  models, and directions for addressing the need to
  monitor the developmental vulnerability of
  children in foster care

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Some statistics

• Very little Canadian research on this population
• Over 76,000 foster children in Canada
• Approximately 500 000 foster children in USA,
  with 230 000 entering foster care every year
  (Antoine Fisher, 2006)
• Young children are the largest group of children
  living in out-of-home care

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Some statistics

• Most common reasons for placement in care
• Neglect (30-59)
• Parental incapacity including substance abuse and
  mental illness (30-75)
• Physical abuse (9-25)
• Abandonment (9-23)
• Sexual abuse (2-6)

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Contributing Factors
Parental Challenges
Substance abuse Mental Illness Intellectual
Limitations Social isolation Domestic violence
Interactive Cycle
Child Factors
Environmental Stressors
Poverty Unemployment Poor nutrition Lack of
social supports Overcrowding
Difficult Temperament Poor Self-Regulation Behavio
ral issues Intellectual Developmental
Limitations
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Issues predating placement in care

• Prenatal history
• Poor prenatal care
• Prenatal exposure
• Genetic conditions
• Transmission of parental challenges
• Developmental disabilities and other
  exceptionalities

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Issues predating placement in care

• Abuse and/or Neglect
• Physical, emotional, sexual abuse victims more
  likely to receive mental health services than
  neglect victims where standard of care is not met
  despite the knowledge that neglect can be more
  detrimental to development (Pears Fisher, 2005)
• Developmental outcomes highly impacted by
  maltreatment, including peer interaction,
  self-control, internalizing behaviors, and
  hyperactivity (Buehler et al., 2000 Veloz
  Fordham, 2005)
• Children birth to 3 highest victimization rate of
  child maltreatment (US Department of Health and
  Human Services)

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Issues predating placement in care

• Placement in care of a relative
• Continuation of kinship ties
• Lack of significant relationship with child prior
  to child entering care
• Preparedness to parent
• Life stage
• Pre-existing issues
• Substance abuse
• Parental substance abuse (biological parent) is
  one of the strongest predictors of foster care
  placement instability (5-9x) this instability
  exacerbates existing behavioral difficulties
  (Holland Gorey, 2004)

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Issues predating placement in care

• Experience of poor parental strategies
• Deficient family management skills
• Harsh and inconsistent discipline
• Low levels of supervision and involvement in
  childs life
• Lack of appropriate prosocial reinforcement
• (Leslie et al., 2005)

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Issues arising with placement in care

• Loss/trauma
• Birth parent(s)
• Siblings (Leathers Addams, 2005)
• Consideration of age at placement
• Change in attachment classification (to secure)
  more likely and more quickly in younger children
  (Stovall-McClough Dozier, 2004)

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Issues arising with placement in care

• Frequent changes in care providers
• of transitions directly impacts development
  (Pears Fisher, 2005)
• Exacerbates existing social and emotional
  concerns (Newton et al., 2000)
• most any child who has already experienced a
  number of lifespan traumas and then the loss of
  their family of origin will only be further
  harmed by going through a series of developed and
  then lost relationships with foster parents and
  siblings. (p. 117-188, Holland Gorey, 2004)

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Issues arising with placement in care

• Quality of care
• Discontinuity in or lack of service provision
  (Pasztor et al., 2006)
• Physician
• Early Intervention Services
• Education
• As childrens skills are tied to their
  environment, a move to foster care can therefore
  suppress child performance during a screening
• We may initially see a child experiencing delays
  who then catches up with time in care

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Clinical Snapshot

• Children in foster care have 3 to 7 times as many
  health conditions, emotional problems and
  developmental delays
• Broken down by age, one American study found that
  children in foster care have the following
  incidences of developmental or emotional problems
• 0 - 12 months 76
• 1 3 years, 83
• 3 - 5 years, 92

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Clinical Snapshot Medical Issues

• Among the most medically fragile children
• Problems begin prenatally
• Prenatal exposure maternal substance use
  poverty
• 82 of children in care (US) had at least one
  chronic medical condition 29 had 3 or more
• Much higher incidence of problems associated with
  prenatal exposure for the population of children
  in foster care

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Clinical Snapshot Medical Issues

• 40 are born prematurely or have low birth weight
• Congenital infection rates are higher (HIV)
• Shaken baby syndrome and physical abuse
• Failure to thrive
• Most common medical conditions include asthma,
  anemia, vision and hearing problems, and
  hyperphagia

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Clinical Snapshot Mental Health Issues

• While up to 50 of children in one study
  reportedly had mental health needs, very few of
  them actually accessed the appropriate services
  due to lack of identification and/or barriers to
  service accessibility within the system (Leslie
  at al, 2000)
• Other studies place the incidence of clinically
  diagnosable mental health issues for children in
  foster care at up to 90

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Clinical Snapshot Mental Health Issues

• Placement in foster care often follows an
  experience of profound neglect, severe or
  prolonged abuse, exposure to violence, or
  grossly disturbed or noncontingent input from a
  psychiatrically impaired or substance abusing
  parent. Many children have had multiple
  caregivers, either before or while in foster
  care. In the youngest cohort of children entering
  foster care, these adverse events occur during
  the most formative time for the development of
  self-regulation and attachment, the primary
  developmental task of infancy and early
  childhood. (Vig et al., 2005)

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Clinical Snapshot Mental Health Issues

• Placement in foster care associated with higher
  rates of behavior issues/disorders (Flynn Biro,
  1998)
• Most common root cause of mental health problems
  for children in foster care is attachment
  disorders
• These are children who have often endured
  multiple losses of their primary attachment
  figure(s)

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Clinical Snapshot Mental Health Issues

• Regulatory disorders are also very common
• inability to establish regular patterns in sleep
  or eating, and/or to modulate emotion, attention,
  activity level, or aggression.
• Result in significant behavioral issues

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Clinical Snapshot Mental Health Issues

• Higher incidence of sleep disorders
• Higher incidence of PTSD
• Expect hyperarousal, hypervigilance, difficulty
  concentrating, developmental regression
• Often over diagnosed as having ADHD when the real
  problem is attachment, trauma or regulatory based.

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Clinical Snapshot Mental Health Issues

• Exposure to higher levels of cortisol in
  extremely critical period of brain development
• Higher levels of cortisol created by many of the
  issues that predate placement in care and arise
  with placement in care (neglect, maltreatment,
  attachment, loss, trauma, etc.)
• More recently, evidence that certain therapeutic
  interventions can actually counteract the effects
  of this early exposure to higher than normal
  levels of cortisol (e.g. Fisher et al., 2007 see
  also Gunnar, M. and colleagues)

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Clinical Snapshot Mental Health Issues

• Mental health services are typically more
  difficult to access than physical health services
  (Pasztor et al., 2006)

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CLINICAL SNAPSHOT DEVELOPMENTAL CHALLENGES

• Decreased levels of educational success
• 41 repeat grade
• 43 in Special Education (3-4x)
• Frequent changes in educational setting (2x)
• (Flynn Biro, 1998)

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CLINICAL SNAPSHOT DEVELOPMENTAL CHALLENGES

• Prevalence of developmental delay 13-80 compared
  to 4-10 in general population (Halfon et al.,
  1995 Horowitz, Simms Farrington, 1994 Leslie
  et al., 2002)
• Decreased language development across all ages
  but worsens as as enter preschool years (up to
  63 will have delays) (Halfon et al, 1995 Silver
  et al, 1999)
• 63 cognitive delays and 46 motor delays (Leslie
  et al, 2002)

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Clinical Snapshot

• Early Interventionist Perspective
• Often start with regulation difficulties
  possibly related to prenatal factors
• Difficulty with self-soothing
• More likely to have extreme and sudden changes in
  their emotional state ( unexplained crying,
  tantrums)
• Catch up may happen with developmental delays but
  social and emotional difficulties often last

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Developmental Screening Project Resource Group

• Dana Brynelsen Provincial Advisor, Infant
  Development Program
• Lorraine Aitken Provincial Advisor, Supported
  Child Dev. Program
• Janet Donald Office of the Child and Youth
  Officer
• Christine Scott Director, Simon Fraser Society
  for Community Living
•  
• MCFD Staff
• Bruce McNeill Director of Child Welfare
• Deputy Director of Adoption
• Susan Waldron Manager of Practice Development
• Pat Scriven Adoption Consultant
• Carol Arkinstall Guardianship Consultant
• Patricia Ghobrial Guardianship Consultant
• Diane Swansburg Residential Resources Consultant
• Sue Khazaie Early Development Consultant

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Fraser Region Developmental Screening Project for
Young Children in Foster Care

• Targeted children-in-care in the Fraser Region in
  March 2005
• not recently screened not currently receiving
  services
• Foster/birth parents completed developmental
  screening inventories
• Ages and Stages Questionnaire (ASQ)
• Ages and Stages Questionnaire Socioemotional
  (ASQSE)
• Parent administered
• Valid and reliable estimates of childrens
  developmental status
• Commonly used to monitor high-risk populations
• Several domains
• ASQ fine motor, gross motor, communication,
  problem solving, personal-social
• ASQSE Self-regulation, compliance,
  communication, adaptive functioning, autonomy,
  affect, and interaction with people)

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FRASER REGION DEVELOPMENTAL SCREENING PROJECT FOR
YOUNG CHILDREN IN FOSTER CARE

• Screening results computed
• Follow-up visit from experienced interventionist
• Referrals for further assessment
• Referrals for developmental supports

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Target Sample
Children in Foster Care in Fraser Region, March
2005 N 454
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Target SampleData Collection Challenges
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Results
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Intensity of Risk
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Domain of Risk
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Follow-up and home visits

• Foster parents with children receiving at-risk
  scores were contacted within 4 weeks
• Follow-up visit arranged
• 55 children flagged for follow-up
• 19 home visits completed
• 3 children with borderline scores had notable
  improvement so no home visit required
• 26 already receiving services when contacted for
  home visit
• 7 no longer in care, moved, over age 5,no longer
  concerns/received services

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Follow-up and home visits

• Experienced early interventionist that worked in
  the geographical area where flagged foster child
  resided visited the involved family
• Reviewed screening results
• Established concerns
• Discussed/facilitated appropriate referrals
• Provided suggestions to encourage further
  development in at-risk areas
• Intervention plan devised, completed and returned
  to social worker

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Follow-up and home visits

• 19 home visits completed
• 14 children for whom referrals for developmental
  supports were made or recommended
• These 14 children had 34 referrals for early
  development services/supports made and an
  additional 10 recommendations for services and
  supports
• 4 additional families received telephone
  consultation

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Project Recommendations

• Systematic developmental screening and
  surveillance program to be developed and
  implemented for all young children in foster care
• Appropriate tool
• Face-to-face
• Foster parent training to include information
  about screening, referral and community services
• Time lines for screening and referral
• Immediate and regular involvement with a
  pediatrician

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Project Recommendations

1. Once identified, timely early intervention
   services and therapy without wait times for
   children in care. These services and supports
   should be portable with the child.

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Project Recommendations

• Information should be tracked and readily
  available regarding a childs
• Developmental status
• Services and supports involved
• Foster parent information
• Guardianship and resource worker information

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Recommendations from Literature

• The American Academy of Pediatrics and the Child
  Welfare League of America have published
  guidelines relevant to the health supervision of
  children in care. Among these are
• Initial medical visit within 24 hours of
  placement
• A comprehensive follow-up visit within 30 days
  of placement
• Routine screening for development, mental health,
  dental health and sexually transmitted infections
• In Canada, there remains no practice guidelines
  specifically designed to meet the health care
  needs of children and youth in foster care.
  (Paediatrics Child Health, 2008)

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Fraser Region Early Childhood Screening Program
Year 1 Children in Care

• Partnership between Fraser Health and Ministry of
  Children and Family Development
• Fraser Health started with the dollars for vision
  screening program for 3 year olds
• Linked this to hearing, dental and developmental
  screening at 18 months and 3 years
• Year 1 are piloting this program for children in
  foster care
• In the first 4 months, there have been 40
  children screened in the Region
• Overall 69 of children required referral for
  further evaluation in at least one facet of the
  screening
• (Early Childhood Screening Program May 2008)

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Every Child MattersLooked After Children - UK

• Developed after the 2003 Victoria Climbié inquiry
  
• 108 recommendations were made by Lord Laming

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Every Child MattersLooked After Children - UK

• At the heart of the recommendations was
  interagency coordination and communication
• Care for children in care is managed within each
  Primary Care Trust (PCT)
• The Children Act 2004 gives a particular role to
  Local Authorities in setting up the arrangements
  to secure co-operation among local partners, such
  as Primary Care Trusts, Youth Offending Teams,
  the Police Service, District Councils and others
• Children are systematically tracked, screened and
  monitored over time
• Thanks to Elaine Offler, CHN Maple Ridge and Pam
  Munro, RN, BScN, MSN Clinical Nurse Specialist
  Community Child and Youth Health Promotion and
  Prevention Fraser Health