Health Problems of Children in Out of Home Care – Results from a Health Screening Clinic Dr Dimitra Tzioumi Dr Dania Nathanson Child Protection Unit Sydney Children’s Hospital

Children in Out of Home Care Australian Statistics Health Screening Clinic setup Results of screening at 1 year Literature findings Recommendations

Australian Statistics In , 12,531 children entered care At 30 June 2005, there were 23,695 (4.9/1000) children (0-17years) in care Approx 38% under 5yrs (13% under 1yr), 27% 5-9yrs, 27% 10-14yrs, 8% 15-17yrs Indigenous children overrepresented – 6 times

Children in Care & Health Vulnerable group of children High health needs Unrecognised health needs Unmet health needs Recent interest to address these needs

Health Screening Clinic for Children in Out of Home Care Local initiative between the Children’s Hospital child protection service and the local office of the Department of Community Services (DOCS) Clinic started February 2005 Clinic accepted referrals only from DOCS

The clinic setup Multidisciplinary clinic Medical and psychosocial staff Pre-assessment health questionnaires Comprehensive physical examination Hearing assessments – audiology Developmental screening Report to DOCS Recommendations

The Clinic Results 101 children Age range: 3m to 14yrs 50% (50) were under 5yrs 43% girls, 57% boys Time in care ranged from 1 week to 6 years 46% were in their first placement

Health Problems -1 Immunisations – 67% up to date Vision – 21% (17/81) failed screen and referred »5 Squint »10 Poor Visual Acuity »1 Floater 14(14%) pre-existing eye conditions

Health Problems -2 Dental –27% caries Hearing - 27% (21/77) failed hearing test »6 ENT referrals »1 sensorineural hearing loss »2 required ‘grommets’ (ventilation tubes)

Health Problems - 3 Development –65% of under 5s failed screen –2 autistic behaviours Speech Delay –52% of under 5s –16% of over 5s Growth –Small stature – 9% –Overweight / Obese– 4%

Health Problems - 4 Infections – 14 (14%) –Respiratory – URTI, ear –Skin –impetigo, infected eczema, warts, fungal Skin – 24 (24%) –Eczema –Scars –Nappy rash –Impetigo –?psoriasis

Health Problems - 5 Recurrent Urinary Tract infections * Investigation for seizures BIRP referrals Asthma* Enuresis Snoring Preauricular skin tag Orthopaedic problems Constipation Recurrent vulvovaginitis Allergic rhinitis Iron deficiency * High arched palates

Health Problems -6 Behavioural and Emotional health –Most significant issue in 60% Significant mental health issues –Depression –Suicidal thoughts –Significant grief and loss issues requiring counselling –Post Traumatic Stress Disorder –Gender identity issues

Emotional Health Problems Attachment issues Grief and loss Separation issues Reactions to contact visits Parentification * Aggression Poor self esteem Poor social skills Rage Food hoarding and overeating Sexualised behaviour Stealing and lying Drug and alcohol School expulsion Placement breakdown

Health needs of children in Out of Home Care -Evidence from the literature

Children at risk for poor health High prevalence of abuse and neglect Poverty and social disadvantage Biological weighting with parents with mental health and drug and alcohol problems *Egelund and Brunnquell, 1979

Children at risk for poor health Rosenfeld 1997 – risk factors for learning and behavioural problems, teenage pregnancy and/or mental health problems. –Risk defined as poverty, perinatal stress, maternal education, family discord, parental alcoholism or addiction, parental mental illness etc. –4 risk factors at age 2yrs increase risk of poor outcomes –On average, foster kids had more than 14 risk factors *J Am Acad Child Adolesc Psychiatry

Risks to Physical Health Antenatal – drug exposure, poor maternal nutrition, poor antenatal care Postnatal – poor nutrition, medical neglect, psychosocial deprivation, inadequate preventive health such as immunisations *Simms, 2000, Pediatrics

Risks to Development Neglect has profound and long lasting effect on all aspects of development Particularly speech and language skills although has global effects *Am Acad of Pediatrics, 2000

Risks to Mental Health Likely to have formed attachments to mentally ill, substance abusing or emotionally unavailable parents Effects of abuse and neglect Trauma of forced separation from parents Demand for rapid adjustment to separation Unstable and temporary situation

Risks to Mental Health cont.. Social isolation – new schools, friends, neighborhood Sense of rejection and abandonment Irrational beliefs about reasons for placement Resentment towards adults who control life Concern about relationship between foster and biological parents

Health on entering Care 13% had normal examination 25% failed vision screen 15% failed hearing screen 20% dental caries 33% under-immunised 20-60% under 5s with developmental delays 35-85% significant emotional or behavioural problems *Chernoff (1994) Pediatrics *Takayama (1998) Pediatrics

Health status in Care Being in care does NOT ameliorate these health problems Poor uptake of immunisations Inadequate dental care Up to 60% developmental difficulties 45-76% chronic medical conditions 84% developmental or psychological problems *Takayama (1998) Pediatrics

Barriers to health care -1 Poor transfer of health information –Minimal medical history available –Frequent placements –New health care providers –Often no ‘bluebooks’ –Often no medicare cards –Changes in caseworker *Am Acad Ped (2002)

Barriers to health care - 2 Lack of advocate – too many adults involved, none takes responsibility Issue of consent and confidentiality and privacy Funding Resources (In)Experience of health professionals

Barriers to health care -3 Tendency to rely on carers to report ill health –relying on carer/caseworker identifies only about 30% of children with developmental delay –Carer report identified 33% with emotional, behavioural or developmental problems cf to 84% on careful assessment *Simms et al (2000) Pediatrics * Halfon et al (1995) Arch Ped Adol Med

HEALTH OF CHILDREN IN OUT OF HOME CARE FUTURE DIRECTIONS

Health Care for Children in Out-of-Home Care Recommendations Routine health assessments on entry into care Ongoing monitoring of health needs Timely access to therapeutic services Transferable health records Health care coordination between agencies Adequate government funding * RACP guidelines

CREATE Health Report Card Recommended Actions Health Care Planning must include: –Maintaining and accessing health records –Initial health screening and assessment –Ongoing planning and review (6-12 month reviews) Service collaboration at local level Monitoring and review – data collection Research into the health needs of children in OOHC