The high levels of unrecognised and unmet health needs of children in care and inequitable access to health care services has been noted in a range of studies and literature. Consequently, specific recommendations for the health care of children in out-of-home care have been in place in both the United States and the United Kingdom for a number of years.85
United KingdomIn the United Kingdom (UK), regulations under the Children Act (1989) recommends a statutory annual health assessment (biannual if under 5 years of age). The initial health assessment includes information gathered from the child, social worker and parent/carer as well as a physical examination. The physical examination includes an assessment of hearing, vision, growth and developmental evaluation.
The UK does not have a mandatory reporting system and has a strong legally-based focus on shared inter-agency responsibility for child protection. In England, although the child protection assessment is carried out by statutory child protection workers, other services such as child health and education now use a ‘common assessment framework’ to identify and respond to a child and family’s needs. This means that only those cases requiring a more specialised statutory child protection assessment are referred to social services.
Recently, new statutory guidance was issued to local authorities, Primary Care Trusts and Strategic Health Authorities. Each Authority must now have regard to the Statutory Guidance on Promoting the Health and Well-being of Looked After Children (November 2009) when exercising their functions.
The Statutory Guidance outlines the following objectives of health assessments:
- assess health risk and provide an opportunity to redress past health neglect, collate health history including peri-natal history;
- ascertain and advise on relevant family history;
- review immunisation status and missed child health screening episodes including dental and oral health;
- assess current health and mental health concerns;
- review and advise on known existing health problems and risk factors;
- ascertain outstanding appointments and places on waiting lists;
- identify unrecognised health needs;
- identify mental health, behavioural and emotional problems;
- recognise developmental or learning concerns;
- plan appropriate action and ensure recommendations are carried through;
- discuss life style issues;
- plan follow up.
be child focused;
- take account of the particular needs of children who are in OOHC and their families, including attention to issues of disability, race, culture and gender;
- be carried out at a time and venue convenient to the child or young person and their carers and parents;
- be sensitive to the child or young person’s needs, wishes and fears;
- include information from all those involved with the care of the children, particularly the birth parents or other previous carers;
- allow sufficient time and preparation for the child to be given a clear understanding of the process and what is involved, so that they have the confidence to fully participate;
- be carried out in a place that facilitates the child or young person’s participation.
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IrelandIn 2003, the Government of Ireland introduced its National Standards for Foster Care.86
A number of elements of the Standards are relevant to the development of the Framework including:
- An assessment of the child’s or young person’s needs is made prior to any placement or, in the case of emergencies, as soon as possible thereafter.
- The decision to use a foster care placement is based on an assessment which determines this to be in the best interests of the child.
- Child and family social workers ensure that the assessments are carried out prior to placement. They are comprehensive and, where appropriate, multidisciplinary. They consider the emotional, psychological, medical, educational and other needs of children and take account of any previous assessments of the children.
- In the case of decisions to place children in foster care in an emergency, the health board ensures completion of an initial assessment of the children within one week of placement and the completion of the comprehensive assessment within six weeks. Unplanned admissions to foster care are made in exceptional circumstances only and the reasons for them are recorded on the case file.
- Children, their families and others involved in their care are encouraged and facilitated to participate in the assessment process.
- Assessment outcomes are shared with the children in an age-appropriate manner and copies of the assessment are given to the family and foster carer/s.
- Decisions are recorded and attached to the assessment report on the case file.
United StatesIn 1988 the American Academy of Paediatrics in conjunction with the Child Welfare League made recommendations to address the health needs of children in care. These recommendations call for an initial medical review before or shortly after being placed into care. This initial physical examination focuses on the identification of acute or chronic conditions requiring immediate attention. All children are then required to receive a comprehensive health assessment within the first month, including a developmental and emotional health evaluation.
In March 2002, the American Academy of Paediatrics’ Committee on Early Childhood, Adoption, and Dependant Care published its statement on Health Care of Young Children in Foster Care. This statement87 reiterated the following principles:
- All children entering foster care should have an initial physical exam before or soon after placement.
- All children in foster care should receive a comprehensive physical as well as a mental health and developmental evaluation within one month of placement.
- Individual court approved social service case plans should include the results of all health assessments and incorporate the recommendations of health providers.
- The physical, developmental and mental health status of a child in foster care should be monitored more frequently than those of children living in stable homes.
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The CARES Institute prepares comprehensive reports and requests that nurses at local offices ask their staff assistants to forward the reports to the patients’ primary care physicians. As part of the process, the Institute actively updates the New Jersey immunization registry, not only with vaccines previously and currently administered, but also with patient lead levels, patient alias names, etc.
Mental health providers see children from aged two, using the developmental assessment Ages & Stages Questionnaires. Developmental assessments are provided until about age 5 yrs, 6 months at which point the screening involves mental health screening. In addition to interviewing the child and accompanying adult (typically the caseworker), IQ and achievement screening measures are used, as well as measures to assess for depressive symptoms, posttraumatic stress symptoms, substance abuse, and a range of other emotional and behavioural symptoms.
Key Learning: Appropriate use of simple screening tools may provide a means of determining the progress of an individual’s health and developmental status over time (and provide a consistent means of data collection for a given population).
Another example of a program designed to assess children entering placement is the Children’s Crisis Care Center (CCCC) in Texas.88 The CCCC is a collaborative partnership in Harris County. Partners in the program include Harris County Children’s Protective Services (CPS), Texas Department of Protective and Regulatory Services, Baylor College of Medicine: Child Trauma Programs, and Harris County’s Mental Health and Mental Retardation Association. The program provides a proactive, up-front, multi-disciplinary assessment of children referred by the child welfare agency. The assessment is performed by a special unit which is completely separate from both the intake/investigation unit and the family maintenance/reunification unit.
A percentage of children and young people entering the CPS system were found to have significant problems across multiple domains. 23% of children were unable to be completely tested due to unresponsiveness, opposition, and/or high emotional distress. Of the remaining children, 62% were found to have at least one developmental delay and over 79% were found to have more than one caution and/or at least one delay on the Denver II scale (a measure that may under-identify some developmental problems). Of those children with delays at their initial screening, 76% had delays in language skills. In other areas, delays were significant with gross motor development being the least effected (only 18%). Within this sample, 60% of children assessed had delays or a clinical presentation that warranted further evaluation or enrollment in specialised early childhood intervention services. Findings further suggest that the longer a child had been in a neglectful or abusive setting, the more pervasive and severe the problems were.
As a group, pilot children and adolescents (6-18yrs) removed from their families by CPS demonstrated many problems. Two of the most striking findings are related to being raised in chaotic and threatening environments. Mild post-traumatic stress (PTSD) symptoms were reported by 86% of this group, with 22% reporting very severe PTSD symptoms. As a group, these children were more proficient at processing non-verbal than verbal information. Academic problems and other neuropsychiatric problems were more common in these children than in the general paediatric population. Findings from an examination of data from the Core Assessments suggest that early assessment of children and adolescents as they enter the CPS system is vital in identifying areas for concentrated treatment and services.
Two types of assessments are provided by the CCCC. A family assessment, which consists of a semi-structured clinical interview and the administration of standardised measures of family, child, and parent functioning which are completed within 72 hours of placement. Within the next 10 to 14 days, a multi-dimensional developmental (for children under age 6) or psychological (for children age 6 or above) screening is completed. The assessment results are reported to the social worker and the court within 20 days of placement. Information from the assessments is used to make recommendations regarding treatment and placement. Program evaluations indicate that assessed children experience fewer placement disruptions, a shorter average time between the initial placement and long-term placement, a higher percentage of relative placements, and higher rates of reunification.
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Key Learning: Models of tiered, multi-domain health assessments have been successfully implemented in other countries. Evaluation of these programs have demonstrated improvements including reduction in placement disruptions and increased restoration.
In April 2008, Texas rolled out a Department of Health and Human Services-funded online Health Passport system. More than 30,000 foster children have electronic records that update most information automatically and follow the child when they move to a new home. At the time of rollout, the system was pre-populated with insurance claims and medical data for these children.
An ERS can be a powerful tool to more effectively collect, store, share, and analyse health information and can improve the health of children in foster care and more efficiently use funding allocated to meet their needs.90
Key Learning: An electronic record system can improve the collection, storage and access to health information and contribute to better health outcomes.
EuropeIn most of Western Europe the assessment of, and response to, children at risk is largely undertaken by non-statutory services.91
Quality4Children – formed via the cooperation of three organisations, FICE (Fédération Internationale des Communautés Educatives), IFCO (International Foster Care Organisation) and SOS Children’s Villages – have developed a quality standard which seeks to improve the situation of children without parental care and support their development. While the Standards have no formal status within the European Union, they have been designed to be directly applied by practitioners.
The key principles outlined in the standards that are relevant to the development of the Framework are outlined below.
- The child is empowered to participate in the decision-making process: All parties involved listen to and respect the child. The child is adequately informed about his/her situation, encouraged to express his/her views and to participate in this process according to his/her level of understanding.
- The out-of-home care process is guided by an individual care plan: An individual care plan is created during the decision-making process to be further developed and implemented during the entire out-of-home care process. This plan is intended to guide the overall development of the child. Generally, the care plan defines the developmental status of the child, sets objectives and measures and clarifies the resources needed to support the overall development of the child. Every relevant decision during the out-of-home care process is guided by this plan.
- Children with special needs receive appropriate care: Caregivers are continuously and specifically trained and supported to meet the special needs of the children in their care.
- The leaving-care process is thoroughly planned and implemented: The leaving-care process is a crucial stage in out-of-home child care and is thoroughly planned and implemented. It is primarily based on the child’s/young adult’s individual care plan. The child/young adult is recognised as an expert regarding the quality of his/her care. His/her feedback is essential for further developing the quality of the care system and the respective care model.
- Follow-up, continuous support and opportunity for contact are ensured: After the child/young adult has left out-of-home care, he/she has the opportunity to receive assistance and support. The care organisation strives to ensure that he/she does not perceive the leaving-care process as a major new disruption. If the young adult has reached the age of majority, the care organisation should continue offering support and opportunity to maintain contact.
85 Nathanson, D & Tzioumi, (2007), Health need of Australian children in out-of -home care. Journal of Paediatrics and Child Health 43 695-9
86 Government of Ireland (2003) National Standards for Foster Care, Department of Health and Children, Dublin
87 American Academy of Paediatrics, Committee on Early Childhood, Adoption and Dependent Care, (2002)
88 Doran, Lee. and Berliner, Lucy (2001) Placement Decisions for Children in Long-Term Foster Care: Innovative Practices and Literature Review Washington State Institute for Public Policy Document No. 01-02-3902
89 Michels Patrick (2008) Electronic Health Records Document Foster Children's Medical Histories. Texas Technology July 22, 2008)
90 Gluckman, Stephanie and Shaw, Terri (2009) Improving Health Outcomes for Children in Foster Care: The Role of Electronic Record Systems – The Children’s Partnership [Executive Summary]
91 Submission to the Special Commission of Inquiry into Child Protection Services in NSW (2008) NSW Commission for Children and Young People