Description

Youth in the care and custody of the state are a vulnerable population. Children and adolescents are removed from the care of parents and placed in foster care when there is substantial concern for their safety. Concomitantly, youth in foster care often present with complex physical, developmental, psychosocial, and mental health needs stemming from exposure to the conditions which lead to placement, including abuse and neglect. The American Academy of Pediatrics recognizes the special medical needs of youths in foster care (1). Yet, there are often barriers including systems issues, access to information, and resources which impact medical care for these youths. Primary care physicians have a critical role in addressing their multiple needs.

Epidemiology

• Approximately 700,000 youth are substantiated maltreatment victims each year with neglect leading as the most common form of maltreatment.
• On any given day, the number of youth in foster care hovers around 400,000 youth nationally, down from just >500,000 in 2002. The average length of stay is 20 months, and foster youth >12 years are less likely to achieve permanency.
• Reunification is the most common exit for foster youth of all ages, although about 26,000 foster youth age out of services annually, most at age 18 years. Some states provide services up to age 21 years following recent changes to federal law.

Etiology and Pathophysiology

• Youth in the child welfare system have early life experiences that affect both their physical and mental health. They have been exposed to traumatic events that are often chronic and cumulative often without the support of a nurturing caregiver to help buffer the effects of trauma.
• The exposure to chronic or severe traumatic events and the subsequent effects on the physical and mental health is a phenomenon called “toxic stress.” Toxic stress chronically activates the body’s neuroendocrine stress response system. This activation has a direct effect on gene translation, immune system response, and neurodevelopment. Chronic glucocorticoid exposure influences the developing brain, placing youth at risk for mental health disorders and also has direct effect on physical health.
• Compared to peers not in foster care, foster care youth have increased rates of infection, asthma, and obesity. Poor health and mental health outcomes can persist into adulthood.

Risk Factors

• Early childhood trauma and adversity places youth at risk for attachment and emotional disruption.
• High rates of adverse childhood experiences increase morbidity and mortality into adulthood.
• Placement instability: Youth who have moved from multiple placements are at risk of poorer physical and mental health care coordination.
• Educational disruptions: Youth who have disruptions in their education are at risk for not graduating from high school.
• Lack of social connections: Youth in foster care often have disrupted network of supports placing them at risk as they enter adolescence and young adulthood.
• Poor access to psychosocial interventions: Foster care youth with behavioral health needs often do not receive therapeutic treatments despite having health insurance.
• Inappropriate psychiatric care: Youth in child welfare are at risk of inappropriate psychotropic medication regimes that are “too much, too many, too young,” whereas many in need of psychiatric services don’t receive adequate care (2)[C].

General Prevention

• Ensuring youth are seen by a primary care physician at point of entry into care, within 72 hours, to assess for any urgent physical health and mental health needs. Youth should then be seen again for a complete evaluation within 30 to 60 days of placement. At that time, medical records should be available for review.
• Given the high rates of mental health disorders in this population, youth should be screened for mental health and substance abuse disorders at the 30-day medical evaluation (3)[C].

Commonly Associated Conditions

• Obesity
• Asthma
• Dental decay
• Sleep disorders
• Developmental delays/attachment difficulties
• Attention deficit hyperactivity disorder (ADHD)
• Posttraumatic stress disorder (PTSD)
• Depression/substance abuse disorders