DEVELOPMENTAL SCREENING AND MONITORING OF CHILDREN IN FOSTER CARE:

1. DEVELOPMENTAL SCREENING AND MONITORING OF CHILDREN IN FOSTER CARE: Megan Tardif Vanessa Lapointe Sue Khazaie Challenges and Strategies

2. 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

3. 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

4. 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%)

5. Contributing Factors Parental Challenges Substance abuse Mental Illness Intellectual Limitations Social isolation Domestic violence Interactive Cycle Child Factors Environmental Stressors Difficult Temperament Poor Self-Regulation Behavioral issues Intellectual & Developmental Limitations Poverty Unemployment Poor nutrition Lack of social supports Overcrowding

6. Issues predating placement in care • Prenatal history • Poor prenatal care • Prenatal exposure • Genetic conditions • Transmission of parental challenges • Developmental disabilities and other exceptionalities

7. 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)

8. 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)

9. 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 child’s life • Lack of appropriate prosocial reinforcement (Leslie et al., 2005)

10. 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)

11. 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)

12. 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 children’s 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

13. 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%

14. 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

15. 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

16. 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%

17. 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)

18. 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)

19. 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

20. 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.

21. 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)

22. Clinical Snapshot – Mental Health Issues • Mental health services are typically more difficult to access than physical health services (Pasztor et al., 2006)

23. 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)

24. 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)

25. 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

26. 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

27. 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 (ASQ:SE) • Parent administered • Valid and reliable estimates of children’s developmental status • Commonly used to monitor high-risk populations • Several domains • ASQ: fine motor, gross motor, communication, problem solving, personal-social • ASQ:SE: Self-regulation, compliance, communication, adaptive functioning, autonomy, affect, and interaction with people)

28. 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

29. Target Sample Children in Foster Care in Fraser Region, March 2005 N = 454

30. Target SampleData Collection Challenges Hi Hi hi aaa aaa xxx

31. Results

32. “Intensity” of Risk

33. Domain of Risk

34. 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

35. 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

36. 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

37. 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

38. Project Recommendations • 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.

39. Project Recommendations • Information should be tracked and readily available regarding a child’s: • Developmental status • Services and supports involved • Foster parent information • Guardianship and resource worker information

40. 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)

41. 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)

42. Every Child Matters:“Looked After Children” - UK • Developed after the 2003 Victoria Climbié inquiry • 108 recommendations were made by Lord Laming

43. Every Child Matters:“Looked 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