By Melinda Young
Foster youth are a vulnerable group that needs more attention and better care coordination when seen in hospitals and community provider settings. This population experiences health disparities when compared with other Medicaid-enrolled children, according to a recent study.1
Research has shown that children placed in foster care experience worse health outcomes than other youth, including three times the prevalence of asthma and obesity and five times the prevalence of mental health conditions.1
“We wanted to compare children in foster care to other children enrolled in Medicaid without foster care,” says James Kaferly, MD, lead study author and director of the Connections for Kids Clinic at the Denver Health and Hospital Authority. “We found that physical and behavioral chronic health conditions were concentrated within a cohort of children in foster care.”
Behavioral Health Is a Great Concern
Kaferly and colleagues used Colorado’s Medicaid administrative data for all enrolled children younger than age 19 years, from July 2011 to August 2020. Children in foster care were identified through Medicaid eligibility codes, and researchers used the Pediatric Medical Complexity Algorithm to describe health condition outcomes. They found that youth in foster care had two to three times higher rates of physical and behavioral conditions. When they assessed data by birth cohort — the month and year of birth — they found that behavioral health condition rates increased with age. Also, the rates of behavioral health conditions among the foster youth were up to eight times greater than among non-foster peers.
“These behavioral health conditions tend to appear in later adolescence and early adulthood,” Kaferly says. “Prior experiences that led a child to be placed in foster care are traumatic and can cause behavioral health conditions.”
It also is possible that behavioral health conditions are identified after a child is removed from the home. Researchers want to learn more about how prior traumatic experiences and removal can have synergistic effects.
“When there are prior experiences and then the child is removed, there could be experiences with child welfare that exacerbate those prior experiences,” Kaferly explains. “Our manuscript is emphasizing having a cross-system collaboration to better understand and think about service delivery for children and see at the population level how we can design healthcare services to try to understand. We need to think about ways systems can work together to evaluate these health outcomes.”
Kaferly and colleagues studied specific differences between youth in foster care and Medicaid-covered youth not in foster care. Those in foster care tended to have been covered by Medicaid for more months than those not in foster care, he notes. Foster children experienced four times higher rates of anxiety than non-foster care children.
“Behavioral and emotional disorders like ADHD [attention-deficit/hyperactivity disorder] was four times higher. Mood disorders were three times higher,” Kaferly adds. “The other part that’s interesting is intellectual disabilities [rates were] more than five times higher in the foster population.”
Consider Trauma
Providers who treat youth in foster care need to consider the effect of trauma on their physical and behavioral health. “Many times, when I see children in our foster care clinic, there are concerns raised by caregivers or case workers about ADHD,” Kaferly notes. “What we don’t fully capture is the sequelae of trauma and how trauma responses are acute reactions and can show symptoms that might mimic ADHD.”
Some of these children might be diagnosed with ADHD, but the underlying cause of their behavioral issue is a trauma-related disorder that has not been identified, Kaferly adds. “ADHD might not be the full explanation,” he says.
The new research punctuates the point that healthcare professionals must be aware that foster children likely experienced trauma — either before and/or because of their removal from their home. For example, Kaferly saw a patient whose foster parents were concerned about the child’s behavior and developmental delay. “As our care progressed with this child, we were able to work in collaboration with child welfare to have a conversation with the birth parents to gain additional information about the child,” he recalls. “This informed our medical information to identify the child had a condition, which was the source of behavioral issues and developmental delay.”
The child needed specialty medical care and child-directed therapies. Providers worked with the foster family and the child’s school to ensure the child received appropriate services. The child began to improve. “It helped the caregiver understand the child’s behaviors. We had home health services support the child in that care, and we had educational services that helped support them in the learning environment,” Kaferly adds.
Collaboration across the care continuum, including social service agencies, is key to successfully caring for this population. “Given our findings of the high prevalence of behavioral health conditions, I would encourage early referral or collaboration [regarding] behavioral health conditions,” Kaferly says. “I hope our work can support and continue to advance a partnership between healthcare and child welfare, so if a child is entering foster care, there is an early connection with healthcare for physical health and behavioral health. There should be coordinated efforts to make sure a child sees a healthcare provider and behavioral health provider.”
Focus on Care Coordination
Care coordination across government agencies and healthcare systems is especially important for children with greater healthcare disparities and issues than their peers. This coordination should include efforts to improve communication. “We can strengthen that so there’s knowledge of when a child enters foster care so that services and interventions can be offered to the child,” Kaferly says. “Also, healthcare recommendations can complement the work child welfare providers are doing to try and minimize health disparities or an exacerbation of health conditions.”
The research highlights the complexity of healthcare for foster children. It also shows how collaboration and care coordination are essential.
“This is a population that has unique medical and social needs, and the way we can help support this group is with coordinated services across the healthcare spectrum,” Kaferly says. “We need to share expertise so we can assist child welfare providers in understanding health conditions and foster children’s vulnerability to health conditions. The two systems inform each other so kids have the best outcomes.”
REFERENCE
- Kaferly J, Orsi-Hunt R, Hosokawa P, et al. Health differs by foster care eligibility: A nine-year retrospective observational study among Medicaid-enrolled children. Acad Pediatr 2023;S1876-2859(23)00471-0.
Foster youth are a vulnerable group that needs more attention and better care coordination when seen in hospitals and community provider settings. This population experiences health disparities when compared with other Medicaid-enrolled children, according to a recent study.
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