THE SPECIAL ROLE OF FOSTER PARENTS

The Caring Communities for Children in Foster Care Project is concluding four years of investigation into the health care needs and availability of services for children in foster care. This project was a collaborative effort between the Parent Educational Advocacy Training Center (PEATC) and Fairfax County Virginia child-serving agencies and was funded by the Maternal Child Health Bureau Integrated Services Initiative with the American Academy of Pediatrics. Using the Medical Home as an approach to supporting the health and well being of children in foster care, this project emphasizes the critical role foster parents play in promoting the health and well being of children in foster care.

The Medical Home approach was developed by the American Academy of Pediatrics (AAP, 1992) to provide high-quality health care services in a cost-effective manner to children with special health care needs. Critical elements of a Medical Home approach include services that are accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally-competent (AAP). Acting as partners with health care professionals, parents are responsible for accessing these services for children.The birth parents of children in foster care should be included and involved in their children’s health care whenever possible. However, when that is not possible, the temporary caregiver, the foster parent, is responsible for ensuring that children in their care receive needed health care services.

Foster Parents: Making a Difference in the Lives of Children in Foster Care

One of the most important lessons learned from talking with foster parents, health care professionals, legal systems representatives and hearing from children who have been in foster care is that foster parents can and often do make a difference!

Foster parents provide so much more than food, clothing and shelter. They attend to homework assignments or fulfill home therapies; they make sure children get to doctor appointments and take medications; they tend to illness, sadness and confusion; and foster parents help children develop skills and confidence to function in the world and move beyond the pain of their past.

Additionally, foster parents may play a pivotal role in helping a child and birth family during reunification. By developing a respectful relationship with a child’s birth family, and serving as mentors for birth families when requested, foster parents often have a lasting positive impact on a child temporarily in their care.

Why Be Concerned About Supporting Foster Parents?

Side by side with stories of success, commitment and caring, foster parents told us of frustrations, humilation, isolation and despair. Foster parents are leaving the profession, saying they can no longer care for the extensive needs of children placed in their care. A lack of the necessary supports to effectively meet the complex physical and mental health needs of the children placed in their care and a generalized feeling that their efforts were not valued by the foster care system are reasons foster parents give for resigning. The picture becomes even more bleak when we realize that as the needs of children in foster care become more complex, the special skills and knowledge that foster parents must possess increases as well. There is an even greater shortage of foster parents who are willing to care for siblings, medically fragile infants,terminally ill children or emotionally disturbed children and teens.

Caring About Children’s Health

Precedents to assure health care services for children in foster care do exist. All children in foster care are eligible for Medicaid if they receive services in foster care according to the Adoption Assistance and Child Welfare Act, Title IV-E of the Social Security Act. Even though the delivery of Medicaid services differs from state to state, the Early Periodic Screening, Diagnostic and Treatment Program (EPSDT) mandates comprehensive and preventative health care services for children from birth to 21 who are enrolled in Medicaid programs. Additionally, the Child Welfare League of America (CWLA) in consultation with the American Academy of Pediatrics (AAP) developed Standards for Health Care Services for Children in Out-of-Home care for child welfare agencies (CWLA, 1988).

Despite these mandates, foster parents are often given little or no information about the physical and mental health of the children entering their home. They face the challenge of finding a physician, particularly a dentist or mental health provider, who will provide services for children covered under Medicaid. Children may be covered by managed care organizations whose health care providers practice outside their local communities. Access to specialists may be limited and those assigned to a child may not be the doctors with whom foster parents have developed previous relationships. Foster parents may feel pressured to accept children whose medical needs are beyond their caregiving abilities given their current status, level of training and comfort level with particular physical or mental health needs. Additionally, training for foster parents may not provide adequate information about basic physical and mental health needs, the safe handling of body fluids, or the need for regular dental checkups. Foster parents may not be aware of how to access services in complicated service systems and they may not understand how much responsibility they should assume for a child.

Children in Foster Care Have Complex Needs

Our discussions with some health care professionals and other members of the foster care system led to the realization that many were not aware of the complex needs of children in foster care. There was typically a differentiation made between children with special health care needs and "typical" children who happened to be in foster care. Our research suggested otherwise. Children enter foster care more vulnerable to negative outcomes (GAO, 1995; Silver, Haecker & Forkey, 1999), and require greater access to mental health services (Morrison, et al, 1999; Rosenbach, 2001) than other children living in similar social and economic circumstances. About 3 million children were reported to state child protective agencies as suspected victims of child abuse and neglect in 1997. Of these reported cases, 984,000 were confirmed as victims of child maltreatment (CDF, 2000). Additionally, we learned from foster parents, former foster children and other experts that children in foster care experience feelings of grief, rage and loss caused by separation from their birth families, no matter how difficult life was for them in their home environment.

According to the Maternal and Child Health Bureau (MCHB) and the American Academy of Pediatrics (AAP), children with special health care needs have, or are at an increased risk for chronic physical, developmental, behavioral or emotional conditions. They require specific types and amounts of health and related services well beyond what is required by children in general (McPherson, et al. 1998). Special attention must be given to the physical and mental well-being of all children in foster care.

Children with Complex Needs Enter a Complex System

Finally children are placed in the care of a "system" responsible for funding and providing care and services for children temporarily removed from their homes while at the same time securing permanent homes for the children and helping birth families to correct the problems that led to their children’s removal. This complex system has been described as being fragmented and under-financed (Simms et al, 1999). The following issues were highlighted by foster parents, social workers and health care professionals as barriers, which interfered with the provision of comprehensive health care services for children in foster care:

• A lack of communication among members of the system;
• Complicated and time-consuming paper work;
• Low reimbursement rates for health care services;
• Complex health plans and numerous gate-keepers;
• Numerous foster placements;
• Lack of or incomplete medical records; and
• A pervasive lack of respect for foster parents and children in foster care.

Add to these barriers, the numbers of social workers leaving the profession, and the future does not look promising for many children who must be removed from their homes for their protection and safety.

Remember the Foster Parents

The barriers are pervasive, but not insurmountable! Increased collaboration within the foster care system and a fresh look at the expertise, professionalism and support needs of foster parents can make a difference in the health and well being of children in foster care. Foster parents need the respect and assistance of other members of the foster care system. Some strategies for partnering and supporting foster parents follow.

• Establish professional relationships.

• Encourage foster parents to attend health related education and mental health trainings.
• Consider the opinions of foster parents.
• Encourage foster parents to attend medical appointments with the child.
• Encourage a foster parent to ask questions and search for answers.
• Help foster parents find ways to pay for extras.
• Help foster parents navigate complex service systems like Medicaid or Special Education.

• Establish methods of efficient communication.

• Provide emergency numbers to foster parents.
• Return phone calls in a timely manner.

• Establish important record keeping methods.

• Encourage foster parents to keep a log, a daily journal, or a health care profile.
• Encourage foster parents to keep track of important school information.

• Strengthen training opportunities for all members of the foster care team.

• Encourage foster parents and other members to attend health related, education, mental health trainings as they become available.
• Facilitate the availability of veteran foster parents who can act as mentors to newer foster parents.

Supporting and meeting the complex needs of a child in foster care cannot be successfully accomplished by only one member of the system. The intricate interdependence of all professionals in the foster care system is key to supporting a child and improving outcomes. Demonstrating support and developing partnerships with foster parents is the first step.

References

American Academy of Pediatrics (AAP), (1992). Policy Statement: The Medical Home (RE9262). Pediatrics 90 (5), 774. [On-line] Available: Internet http://www.aap.org/policy/04992.html

Children’s Defense Fund. (2000). The State of America’s Children. Washington, D.C.: Author.

Child Welfare League of America. (1988). Standards for health care for children in out-of-home care. Washington, DC: Author.

General Accounting Office. (1995). Foster care: Health needs of many young children are unknown and unmet. (GAO publication GAO/HEHS-95-114). Washington, DC: Author.

McPherson,M., Arango P., fox H., et al. (1998). A new definition of children with special health care needs. Pediatrics 102 (1). 137-140.

Morrison, J., Frank, S., Holland, C., & Kates, W. (1999). Emotional development and disorders in young children in the child welfare system. In J. Silver, B. Amster, and T. Haecker (Eds.), Young children and foster care: A guide for professionals (pp. 33 - 64). Baltimore, MD: Paul H. Brookes.

Rosenbach, M. (March, 2001). Policy Brief : Mathematica Policy Research, Inc. Children in foster care: Challenges in meeting their health care needs through Medicaid. [On-line] Available: Internet http://www.mathematica-mpr.com/PDFs/fostercarebrief.pdf

Silver, J., Haecker, T., & Forkey, H. (1999). Health care for young children in foster care. In J. Silver, B. Amster, and T. Haecker (Eds.), Young children and foster care: A guide for professionals (pp. 161-195). Baltimore, MD: Paul H. Brookes.

Simms, M., Freundlich, M., Battistelli, E., & Kaurman, N. (1999). Delivering health and mental health care services to children in family foster care after welfare and health care reform. Child Welfare, 78 (1). 166-183.