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

G OALS 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

S OME STATISTICS Very little Canadian research on this population Over 76,000 foster children in Canada Approximately foster children in USA, with entering foster care every year (Antoine & Fisher, 2006) Young children are the largest group of children living in out-of-home care

S OME 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%)

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

I SSUES PREDATING PLACEMENT IN CARE Prenatal history Poor prenatal care Prenatal exposure Genetic conditions Transmission of parental challenges Developmental disabilities and other exceptionalities

I SSUES 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)

I SSUES 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)

I SSUES 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)

I SSUES 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)

I SSUES 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 , Holland & Gorey, 2004)

I SSUES 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

C LINICAL S NAPSHOT 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 months – 76% 1 – 3 years, 83% years, 92%

C LINICAL S NAPSHOT – M EDICAL I SSUES 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

C LINICAL S NAPSHOT – M EDICAL I SSUES 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

C LINICAL S NAPSHOT – M ENTAL H EALTH I SSUES 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%

C LINICAL S NAPSHOT – M ENTAL H EALTH I SSUES “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)

C LINICAL S NAPSHOT – M ENTAL H EALTH I SSUES 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)

C LINICAL S NAPSHOT – M ENTAL H EALTH I SSUES 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

C LINICAL S NAPSHOT – M ENTAL H EALTH I SSUES 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.

C LINICAL S NAPSHOT – M ENTAL H EALTH I SSUES 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)

C LINICAL S NAPSHOT – M ENTAL H EALTH I SSUES Mental health services are typically more difficult to access than physical health services (Pasztor et al., 2006)

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)

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)

C LINICAL S NAPSHOT 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

D EVELOPMENTAL S CREENING P ROJECT R ESOURCE G ROUP Dana BrynelsenProvincial Advisor, Infant Development Program Lorraine AitkenProvincial Advisor, Supported Child Dev. Program Janet DonaldOffice of the Child and Youth Officer Christine ScottDirector, Simon Fraser Society for Community Living MCFD Staff: Bruce McNeillDirector of Child Welfare Deputy Director of Adoption Susan WaldronManager of Practice Development Pat ScrivenAdoption Consultant Carol ArkinstallGuardianship Consultant Patricia GhobrialGuardianship Consultant Diane SwansburgResidential Resources Consultant Sue KhazaieEarly Development Consultant

F RASER R EGION D EVELOPMENTAL S CREENING P ROJECT FOR Y OUNG C HILDREN IN F OSTER C ARE 1. Targeted children-in-care in the Fraser Region in March 2005 not recently screened & not currently receiving services 2. 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)

FRASER REGION DEVELOPMENTAL SCREENING PROJECT FOR YOUNG CHILDREN IN FOSTER CARE 3. Screening results computed 4. Follow-up visit from experienced interventionist Referrals for further assessment Referrals for developmental supports

T ARGET S AMPLE Children in Foster Care in Fraser Region, March 2005 N = 454

T ARGET S AMPLE D ATA C OLLECTION C HALLENGES aaa xxx Hi hi

R ESULTS

“I NTENSITY ” OF R ISK

D OMAIN OF R ISK

F OLLOW - 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

F OLLOW - 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

F OLLOW - 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

P ROJECT R ECOMMENDATIONS 1. 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

P ROJECT R ECOMMENDATIONS 2. 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.

P ROJECT R ECOMMENDATIONS 3. 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

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)

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)

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

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