Health Problems of Children in Out of Home Care – Results from

a Health Screening Clinic

Dr Dimitra TzioumiDr Dania NathansonChild 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 2004-2005, 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 - 5Recurrent 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 ProblemsAttachment

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 -2006

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