It is likely that foster children will be seen in the family physician's office. Approximately 550,000 children are in foster care in the United States,1(p2) and the number is increasing, especially in children under the age of five years.2 Often, foster children come to the attention of the medical system because they are acutely injured or have a chronic illness related to long-term mistreatment. They are children who were born to alcohol- and drug-addicted parents and have suffered sexual, physical, and emotional abuse before being separated from their parents by court order. More than 80 percent of these children have developmental, educational, and emotional problems.1(p20)
Typically, foster children have more medical problems than other disadvantaged children. They require more of the physician's time, more referrals, and more diagnostic tests. Most foster children are insured by Medicaid, and the compensation that is available to physicians for the effort expended in their care is inadequate. For these reasons, the medical needs of foster children may not be met. A study by the U.S. General Accounting Office3(p6) found that “…12 percent of the (foster) children received no routine health care; 34 percent received no immunizations; 32 percent continued to have at least one unmet health need after placement; and 78 percent of the children were at high risk for HIV, but only 9 percent had been tested for the virus.”
This step includes medical and dental evaluation as well as assessment of the child's developmental, nutritional, and mental health status.
Follow-up is necessary at more frequent intervals than the usual well-child check-ups. Follow-up should address identified problems and care for any new difficulties. It includes visual, hearing, and dental problems, testing for sexually transmitted disease, determination of lead levels, and provision of immunizations.
Coordination with community-based programs is valuable to help the children catch up on educational and developmental delays. The court and social service programs should incorporate health care team recommendations into court-ordered treatment plans.
This element consists of careful and frequent monitoring of the child's progress, both before and after permanent placement. Ideally, this care would be provided by the same physician on an ongoing basis.
Responsibility for coordinating and monitoring health care belongs in the medical office. However, help is available to physicians who care for foster children. Social workers, therapists, and court-appointed special advocate (CASA) volunteers can assist in facilitating care. The CASA worker has access to all records and persons important in the child's life and can contact previous caregivers, schools, and physicians to collect immunization records and medical history for each child.
The CASA worker also can interview parents and relatives to document certain developmental milestones. Further, this trained volunteer is involved with the child until permanent placement is arranged and can provide information about school performance, changes in legal or foster-family status, and other significant life changes.
Help is also available from local social or human services departments in providing guidance for obtaining funds from a myriad of agencies. It is not the physician's job to untie the legal tangle in which some of these children are involved—that remains the responsibility of the guardian ad litem.
Children removed from the family of origin need a medical “home.” The age of the child, and the type and duration of abuse, as well as the holistic care received, influences the child's rate of recovery. Unfortunately, it is difficult to provide continuous, comprehensive care for foster children. When a foster child's health is neglected, hope for the young person's future is dimmed, and the likelihood of a satisfying, productive life is endangered.3(p7) The family physician's willingness to become part of the team that cares for these seriously injured children is of great benefit, and watching a withdrawn, skinny, depressed, abused youngster reenter a joyous childhood is the reward for this hard work.