How do we measure health in children 0-5 years in Out of Home care?

1. How do we measure health in children 0-5 years in Out of Home care? Margaret GOLDFINCH,Diana BARNETT, Stacey BLACK, Holly DONNELLY, Santhini KUMARAN,Anna STACHURSKA, Romina TUCKER The Children’s Hospital Westmead and Redbank House

2. What health needs? • Children in OOHC are a vulnerable “at-risk” group. • This group are likely to have poorer physical, mental and developmental health than their peers. (RACP, 2006) • 45% if all children in care in NSW in June 2010 were 0-6 years old.

3. Neglecting the Needs of Children in the Care System • impacts on placement stability, (Horwitz et al, 2000; Rubin et al 2004) • poor academic achievement • increased risk of mental health problems in adolescence • poor attachment in relationships as adults. (Leslie et al, 2005)

4. National Clinical Assessment Framework (March 2011) Physical Psychosocial and Mental Health Developmental - Developmental history - Speech, language and communication - Motor development - Cognitive development - Sensory - Physical health history - Physical examination and assessment - Oral Health assessment - Health literacy - History - Mental Health - Behavioural - Emotional development - Social competence - Development of identity

5. Why is this work so challenging? • Children/P in OOHC have complex needs • Change of placements/ carers • Change of case workers • Limited medical history • Information lost/ not handed over • No consistent advocate for the child • Contact with birth parents • Kinship/ relative carers- FOI issues

6. SCHN - OOHC clinic model • Comprehensive Multidisciplinary assessments for 0- 5 year olds already in care. • Model based on health, developmental and psychosocial needs identified in literature. • Partnership between ACC, Redbank House and SCHN (Randwick and Westmead) • MD team- Paediatrician, Social Worker/Psychologist, Audiologist, Orthoptist, SP, and OT. Senior Psychologist to provide supervision

7. OOHC Clinic Assessment Background info: • Caseworker makes health referral providing details of background, health information and reasons for entry into care • Questionnaires sent to carers (ASQ3, ASQSE, CBCL, SDQ, PSI-SF) • Teachers- pre-school questionnaire (designed by clinic, four areas- motor performance, pre-academic skills, language skills, social and behaviour)

8. 0-5 yr old OOHC Clinic Assessment Developmental hx ASQ3 review Play assessment Clinical observations during appointment Formal assessment by OT and/or Speech pathologist if indicated Preschool quest’aire Psychosocial and Mental Health Physical Developmental Medical examination Audiology Asst Vision and eye screen Play assessment Interview with carer Observation of child/ carer interaction/ relationship and attachment Address any concerns raised by caseworker Review preschool FB

9. Questionnaires • ASQ3 (Ages and Stages 3)- parent completed, developmental screener, covers communication, gross motor, fine motor, problem-solving, personal-social • CBCL (Child Behaviour Checklist)- assess a child’s behavioural, emotional and social problems and competencies from their parent or carers point of view • PSI (Parenting Stress Index)- measures stress experienced by a carer in caring for a particular child, due to the specific features of the child or the nature of interactions with them

10. ASQ SE (Ages & Stages Questionnaire – Social/Emotional ) monitors a child’s development in the areas of self-regulation, compliance, communication, adaptive, autonomy, affect and interaction with people. • SDQ (Strengths & Difficulties Questionnaire) - focuses on whether a child has difficulty with emotions, concentration, behaviour or getting along with others. • Preschool/ School Questionnaire

11. Referral Information – Search for “Red Flags” • Reasons for Removal • Exposure to DV, abuse, AOD, • Placement History • Age at entry to care, number of placements, any placement breakdowns • Medical history • Genetic vulnerability, perinatal insults, neonatal abstinence syndrome, is child on medications • Any Concerns from carer, child care, agencies • Behaviour (tantrums, aggression),illness, developmental, social skills • Inconsistencies between reports of child’s behaviour in different settings (eg carer and childcare)

12. PaediatricAssessment Medical history Sources of information: • FaCS(pre assessment - health questionnaire), blue book, ACIR, carer, • Medical records (neonatal and other discharge summaries, copy of medical letters), • Reports (AOD centre, psychologists, preschool) Focus on: prenatal exposure to alcohol/ illicit drugs, prenatal exposure to Hepatitis B or C, perinatal complications, family history of developmental /intellectual disabilities, genetics, early growth parameters and how it change over time,immunizationstatus, medications, allergies and current health concerns Physical examination: Focus on: growth, nutritional state, physical evidence of prenatal exposure to alcohol, dysmorphic features & thorough systemic examination ie. respiratory, cardiovascular, neurological, etc… Allied health • Audiology clinic: hearing testing • Eye clinic: vision and eye screening

13. Psychosocial Assessment • Any emotional or behavioral concerns? –eg tantrums, aggression, “spacing out”, sexualized behaviour, regulation problems • Sleeping, eating, settling, comfort seeking, play, peer relations, sibling issues • How these are managed by carer • How does child relate within the foster family? • Response to contact w biological family • Developmental history (if available) • Social and communication skills • Review preschool feedback

14. Semi structured Play Assessment Modified from Crowell Assessment (1988) Approx 20 minutes Play as you normally would Follow child’s lead ( play skills collaboration, reciprocity, enjoyment) Ask child to pack up ( compliance , cooperation) Bubbles (enjoyment, collaboration) Puzzles (skills, attention, concentration, scaffolding, collaboration) Brief separation (3 mins) Reunion Reflection

15. Observations Carer - sensitivity, structuring , intrusiveness, hostility - Availability as a secure base Child -responsiveness, involvement, initiative, regulation, cuing/miscuing carer, imagination - Use of carer as a secure base Dyad – comfort, tension and regulation, joint attention, reciprocity, enjoyment, mutuality Multi D team Observations – developmental/play skills, fine motor, communication, multiple views of same behaviour or interaction -> rich discussion

16. Multi D Team Discussion

17. Steven • 4 year old boy, removed at 24mths • Two short term placements and has been in current placement for last 18 months • Birth parents have intellectual disabilities, two siblings with developmental delay

18. History of neglect , A & D during pregnancy and parental IV drug use (unknown Hep C status) • Starting school next year, attends pre-school 3 days/week • Pre-school worries about his learning, fine motor skills and outbursts of aggression towards peers • Monthly contact with birth family. Carer reports difficulties with his behaviour before/after contact visit

19. Questionnaires: • ASQ- III concerns in communication, fine motor, problem solving and personal social skills • ASQ- SE and CBCL, SDQ- indicate problems with aggression, emotion regulation, concentration and sleep

20. Psychosocial • Carer struggling with his behaviour at home • Stephen has difficulty following directions (observed) • Puzzle skills poor for his age. Carer not able to help him persist and had trouble encouraging him to pack up • Quickly moved between play objects but didn’t persistently engage with any activity to developmental expectations • Steven didn’t acknowledge return of carer after separation, or use her as a ”secure base” during the interview

21. Physical/ Medical • No medical history prior to this placement • Growth - 3rd centile for height and weight (genetic? early neglect or organic ? no previous measurements) • Mild facial dysmorphic features (no biological relatives to compare with) • Dental decay • Sleep difficulties- snores • Hearing assessment: mild conductive hearing loss bilaterally • Unremarkable rest of examination

22. Developmental • Pre-school teacher indicated difficulties at pre-school, poor fine motor skills and inability to follow instructions • Clinic observations and screening questionnaires indicate need for formal developmental assessment • Referred to OT and Speech Pathology within clinic

23. OT Assessment • Completed M-FUN. Scores on fine motor component and visual motor component were below average. • General observations showed some inattention during activities. • Scattering of abilities and experience across different skills eg. Unable to cut along a line, poor drawing skills but aged appropriate self care skills • Carer not having good knowledge of what is appropriate for their age

24. Speech Assessment • Language skills assessed using the CELF-Preschool-2. • Difficulties with following directions accurately. • Expressive language testing revealed reduced vocabulary and short length of utterance for age. • Short attention span noted

25. Health Management Plan (Recommendations) • Continued stability in placement • Support for carer around understanding and managing behavioural presentation • OT &SP referral with Early Intervention • Liaison with Department of Education and Communities (DEC) school planning • Psychometric assessment prior to school

26. ENT referral • Routine oral health follow-up • ?Genetics referral and investigation for DD • Link with Paediatrician and GP - to monitor health, growth and developmental progress • Caseworker to compile all health information and have access to this on file

27. Strengths of Multidisc Team Assessment • Combined interview :- • More than one perspective on behaviour, symptoms or observations which appear contradictory in interview • Allows medical assessment longer time frame • Raises the profile of importance of developmental and psychosocial issues in health management of foster children • Each clinician learns from other disciplines and improves assessment eg evolution of the play assessment • Less clinic visits for carer and child

28. Second occasion and location of assessment by OT & SP • Picked up consistencies in child’s presentation and interaction w carer • Subsequent team discussion • richer and more balanced view of overlapping and complex symptoms and the child’s needs • Combined HMP and Report • Broader view of child’s wellbeing • Greater access to/knowledge about services for follow-up

29. Difficulties we Encountered • Some carers/families uncomfortable or suspicious of emotional or psychosocial assessment • Large time allocation needed for collating information and writing comprehensive report (considerable time) • Single interview – sometimes needed time for discussion and reflection after interview before giving feedback • Background history and information difficult to find due to fragmentation • Different carers have different needs or expectations from the assessment process

30. Questions??

31. Reference: Australian Institute of Health and Welfare (2010) Chambers, M., Saunders, A., New, B. Williams, C. & Stachurska, A. (2010). Assessment of children coming into care: Processes, pitfalls and partnerships. Clinical Child Psychology and Psychiatry.15(4): 511-526. Community Services Annual Report (2010) Horwitz, S., Owens P., & Simms, M. (2000). Specialized assessments for children in foster care. Journal of Pediatrics.106: 59–66. Kaltner, M. & Rissel, K. (2011). Health of Australian children in out-of-home care: Needs and carer recognition. Journal of Paediatrics and Child Health.47: 122-126. Leslie, L., Gordon, J., Lambros, K., Premji, K., Peoples, J. & Gist K. (2005). Addressing the developmental and mental health needs of young children in foster care. Journal of Developmental and Behavioral Pediatrics. 26: 40–51.

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