Overview

Prevalence

Genetics

Prognosis

• 47% were reunited with parent(s) or primary caretaker(s)
• 26% were adopted
• 11% went to live with a guardian
• 8% were emancipated or “aged out” of the foster care system when they became too old (usually at age 18) to receive further services
• 6% went to live with another relative
• 1% had other outcomes (includes transferal to another agency, running away, or death)

Practice Guidelines

Szilagyi MA, Rosen DS, Rubin D, Zlotnik S.
Health Care Issues for Children and Adolescents in Foster Care and Kinship Care.
Pediatrics. 2015;136(4):e1142-66. PubMed abstract / Full Text

Keeshin B, Forkey HC, Fouras G, MacMillan HL.
Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication.
Pediatrics. 2020. PubMed abstract

Jones VF, Schulte EE, Waite D.
Pediatrician Guidance in Supporting Families of Children Who Are Adopted, Fostered, or in Kinship Care.
Pediatrics. 2020;146(6). PubMed abstract

American Academy of Pediatrics, Council on Foster Care, Adoption, and Kinship Care and Committee on Early Childhood.
Health care of youth aging out of foster care.
Pediatrics. 2012;130(6):1170-3. PubMed abstract / Full Text

Keeshin BR, Bryant BJ, Gargaro ER.
Emotional Dysregulation: A Trauma-Informed Approach.
Child Adolesc Psychiatr Clin N Am. 2021;30(2):375-387. PubMed abstract

Kerker BD, Zhang J, Nadeem E, Stein RE, Hurlburt MS, Heneghan A, Landsverk J, McCue Horwitz S.
Adverse Childhood Experiences and Mental Health, Chronic Medical Conditions, and Development in Young Children.
Acad Pediatr. 2015;15(5):510-7. PubMed abstract / Full Text

Roles of the Medical Home

• Knowledge about the child welfare system and consent process in your state
• Supporting access to care and caregiver support through phone consultation
• Obtaining and maintaining updated medical records
• Implementing trauma-informed care and best practice guidelines

Toxic Stress Toolkit (AAP) ( 11.4 MB)

Overview

Bright Futures/AAP Periodicity Schedule ( 119 KB)

Bright Futures Guidelines for Health Supervision - Pocket Guide, 4th Edition (AAP) ( 5.1 MB)

• Collect and update demographic information, identify the type of placement, past medical, family, and social history, and reason for out-of-home placement.
• Conduct a complete physical examination, including detailed descriptions of dermatological and other pertinent exam findings.
• Identify needs that require prompt attention, including assessment for acute injuries, chronic medical conditions, regular medications, suicide risk, and acute mental health conditions.
• Refill any medications needed before next assessment, place any urgent referrals.
• Schedule follow-up and obtain medical records.
• Identify the system of communication and care coordination with Child Welfare in your state.

• Collect comprehensive history and conduct a complete physical exam.
• Conduct age-appropriate, standardized, developmental and trauma screening; reassess for acute injuries, chronic medical conditions, regular medications, risk of harm to self or others, and substance use. For all adolescents, include a HEADSS Assessment ( 72 KB) without the caregiver in the room.
• Identify gaps in care. Update medication list, provide medication refills as needed, update problem list and prioritize needs. Develop a care plan with dental, mental health, and specialty care referrals as indicated.
• Provide trauma-informed anticipatory guidance. Provide support and psychoeducation around the impact of adverse childhood experiences and trauma on child behavior and self-regulation. Help foster parents identify trauma triggers, set appropriate expectations, and promote trauma-informed treatment and resiliency.

• Coordinate care, including referrals, follow-up, and communication with the Child Welfare System.
• Identify team members, including social workers, mental health clinicians, school personnel, subspecialists, others as indicated.
• Continue regular return visits every 3-6 months or with placement changes.

• Ask about interval changes in social history. Youth in foster care may experience disruption in placement for different reasons. Ask about the current placement and how long the child has been living in this placement. Does the child have other siblings? If so, where are their siblings living?
• Visitations: Do they have visitations with parents and/or siblings? Are the visitations supervised? Where do they occur?
• Demographic information: Maintain updated demographic data. Include the name and contact information for the child welfare social worker (usually they are the emergency contact). Maintain the confidentiality of foster parent(s) by entering their name and contact information in the designated confidential demographic section of the health record.

Pearls & Alerts for Assessment

Look for physical, developmental, and emotional health conditions common in children who have experienced trauma. Consider the impact of adverse childhood experiences and traumatic stress on brain development. See youth in foster care frequently, assess safety, look for gaps in care, know who can make decisions, and be aware that trauma can mimic many physical and psychiatric diagnoses. Include trauma screening, physical, dental, and developmental assessments and monitoring. Refer as needed to mental health specialists for evaluation and trauma-based treatment.

Biological and environmental risk factors, as well as adverse childhood experiences and traumatic stress, increase the risk for physical, developmental, behavioral, and mental health concerns. [Shonkoff: 2012] Exposed children may have problems with self-regulation (sleep disturbances, eating problems, or toileting problems) and symptoms of depression, anxiety, ADHD, aggression, self-injury, and anger that persist long after the child has been removed from the abusive or neglectful environment. Children may develop symptoms related to separation from their home and other familiar environments, which may be the most traumatic aspect of entering foster care. Primary care providers can help caregivers identify altered responses, formulate effective coping strategies, and mobilize available community resources. [Stirling: 2008]

Most children in foster care have been exposed to traumatic events beyond what is known or reported. Children may not be ready to discuss past trauma during the initial visit. Use positive and supportive language to build trust and support the child’s sense of self. The child may be willing to talk to their health care provider about past events, such as other physical or sexual abuse, that they have not previously disclosed. Discuss limits of confidentiality using developmentally appropriate language.

While set routines in a predictable home can help some symptoms, many children struggle to engage in trauma-focused mental health treatment because of inattention, impulsivity, and hyperactivity. Start with mental health screenings, including measures assessing traumatic events and trauma symptoms, refer for evidence-based, trauma-focused treatment and additional evaluation as needed in consultation with the child’s mental health therapist. [Fraser: 2019]

Disruptions in care, continuity of care, and schooling can occur at the entry in foster care, during placement changes, or visits with the family of origin and can lead to increased emergency room use. [Rubin: 2004]

Direct contact with previous health care providers or review of previous medical records (e.g., from schools or immunization registries) may enable reconstruction of the child’s health, medication, and immunization history. The child may have been known by other names, and birthdates may be inaccurate. Verify current medications and reconcile medication lists that may be present in the electronic medical record. If immunization information is unavailable, children should be considered susceptible and immunized according to guidelines. [Szilagyi: 2015]

For Complications

• Traumatic Stress in Pediatric Patients Care Process Model () may be used to identify the types of traumatic events a child has experienced and related symptoms.
• SEEK Parent Screening Questionnaire (PSQ-R) is a free, parent screening questionnaire that targets risk factors related to child maltreatment. It is available in 4 languages and recommended for youth under 5 years.
• Comprehensive resources and screening tools are available in the Toxic Stress Toolkit (AAP) ( 11.4 MB).

Medical Screening Reference Table (Bright Futures) ( 1.0 MB)

Presentations

Comorbid & Secondary Conditions

• Asthma (Asthma)
• Growth concerns
• Metabolic syndrome
• Dental caries and other dental conditions (Dental and Oral Health Screening)
• Infectious disease
• Inadequate immunizations
• Vision and hearing issues (Hearing Screening)
• Developmental delay, speech and language problems, learning disability other neurodevelopmental disabilities (e.g., Fetal Alcohol Spectrum Disorders, Autism Screening, Developmental Screening)
• Emotional dysregulation
• Sleep disturbances (Screening for Sleep Problems)
• Mental health problems
  • Attachment disorder
  • Post-traumatic stress disorder (PTSD)
  • Depression, anxiety, and other mood disorders (Mental Health Screening for Children & Teens, Infant & Early Childhood Social-Emotional Screening)
  • Behavioral disorders, such as attention-deficit/hyperactivity disorder (ADHD), oppositional-defiant disorder (ODD), and conduct disorder (CD) (Attention-Deficit/Hyperactivity Disorder (ADHD))

Current & Past Medical History

Family History

Pregnancy/Perinatal History

Developmental & Educational Progress

Maturational Progress

Physical Exam

Sensory Testing

Laboratory Testing

• Anemia
• Lead level
• Tuberculosis (purified protein derivative tuberculin (PDD) if 3 months or older; or quantiferon -TB gold test)
• HIV
• Hepatitis B
• Hepatitis C
• Sexually transmitted infection
  • Chlamydia, gonorrhea, syphilis, and HIV testing if risk assessment is positive. Follow universal screening guidelines, including HIV screening once between 15 -18 years of age. (Check state policy regarding who can give consent for testing and confidentiality of test results.) Bright Futures/AAP Periodicity Schedule ( 119 KB)
• Pregnancy testing (Check state policy regarding who can give consent for testing.)
• Evaluation for metabolic syndrome
  • Fasting serum triglyceride levels (>110mg/dL)
  • Fasting HDL-cholesterol (<40mg/dL)
  • Fasting glucose (>110mg/dL)
  • HbA1C (5.7 - 6.4 pre-diabetes; >6.5 diabetes)
• Consider maternal labs for evaluation of newborn

Imaging

Other Testing

Overview

• Assess safety (just because they are in custody does not mean they are safe)
• Be aware of placement disruptions, look for gaps in care and services, may need prescription refills
• Know who can make medical decisions
• Provide education and support to caregivers, continuity, tracking, and care coordination
• Symptoms of trauma can mimic many physical and psychiatric diagnoses
• Be an advocate and liaison with child welfare

Pearls & Alerts for Treatment & Management

Motivational interviewing can be a valuable technique for approaching risk-reduction counseling and contraception with adolescents. Motivational Interviewing (MINT) provides details of this technique.

Consider the health literacy of the child and foster parents when formulating and discussing the treatment plan. Also, share the treatment plan with the child’s caseworker and birth parents if appropriate.

Providing primary care for children in foster care presents several dilemmas for the clinician. First, the caregiver who accompanies the foster child may be the foster parent, the child welfare worker, or simply a transport provider. They may be most interested in resolving an immediate problem (e.g., the child needs to be calmer or go to sleep) and may not address long-term concerns or issues as most parents would. This places greater responsibility on the primary care clinician to consider and advocate for the child’s long-term needs and interests. Discontinuity of care and lack of access to medical records are often a challenge since the foster parents may prefer not to (or are unable to) continue care with the child’s previous primary care clinician.

Multiple psychotropic medications are often prescribed to manage behavioral symptoms. This may be driven in part by relatively short-term goals that may not be in the child's long-term best interest. Addressing the latter and collaborating with foster care programs to access services that help foster families manage symptoms non-pharmacologically may be useful.

Development (Cognitive, Motor, Language, Social-Emotional)

Prescription Medications

Systems

Family

Foster, Kinship, Adoptive Families
Clinicians need to understand the complexities of the child’s current living situation to support the child and the family. Become familiar with the child welfare system in your state. One-quarter of placements are likely to be in kinship care. Fifty-nine percent of children exiting foster care in 2018 returned to a parent or primary caregiver, 25% were adopted, 7% lived with other relatives (kinship care). [Children's: 2019]

Multiple studies support the benefit of kinship placements. To help these placements succeed, clinicians can help families understand the effects of adverse childhood experiences and encourage developmentally appropriate expectations and responses to the child. Lay a foundation for a child’s later understanding of foster care and self-identity by encouraging conversation using developmentally natural discussions about foster care, adoption, and birth family. Help families acknowledge racial and cultural differences. Be aware of the complexity of losses experienced by foster, adoptive, and birth parents; provide support and facilitate mental health referrals as needed. [Jones: 2020]

Caregiver Support
When parents or foster parents report significant behavioral or emotional problems with a child, consider their capacity to manage the child’s behaviors without emotional or physical abuse. Referral for respite care may be useful or, if punishment appears to be abusive, child protective services should be contacted.

Help families understand the potential for trauma-induced aberrations in bodily functions and behaviors and help determine the need for intervention. Understanding responses to trauma can help families set appropriate expectations. Toxic Stress Toolkit (AAP) ( 11.4 MB) provides useful information to begin this educational process.

Mental Health/Behavior

Impacts of Toxic Stress
Trauma-related toxic stress may result in neuro-dysregulation and explain behavior problems commonly observed in children that may be misidentified as ADHD, ODD, or conduct disorder. Understanding the impact of ACES and traumatic experiences on development provides a framework for caring for children and youth in foster care. See Toxic Stress Toolkit (AAP) ( 11.4 MB).

In addition, agitation, anxiety, and poor attention are common responses to entering foster care and a new, unfamiliar home. Children and teens often grieve the separation from their family and feel confused by what has happened. These symptoms should be evaluated and followed to determine if they are transitory adjustments to foster care, recovery from exposure to past trauma, or a psychiatric disorder, such as ADHD or post-traumatic stress disorder..

Triggers
Family visitations will be part of the child welfare plan. Initially, the child may have no contact with their family of origin. When deemed safe, supervised visits and, depending on progress toward reunification, visits will become more frequent. Although visitation with their parents may be healing when they go well, they may bring back separation, loss, fear, and anger. It is common for children to be emotionally reactive following a visit. [Winokur: 2018] Foster families may seek guidance on managing changes in eating patterns, emotional dysregulation, and sleep following visits. For a helpful handout to guide foster families, go to Parenting after Trauma: Understanding Your Child’s Needs (healthychildren.org).

The primary care clinician may feel pressure to start or continue and monitor use of psychotropic medication(s) when they see 1) a child or adolescent as they transition from a residential setting where medicines were used, 2) a child in jeopardy of losing their foster placement or having school problems due to behavior, or 3) the caregivers and caseworkers are not able to provide an adequate past or present history.

However, psychotropic medications may not be in the child’s best interest. Disruptive behaviors, such as aggression, defiance, and temper tantrums/outbursts, may indicate a reaction to traumatic events, which does not respond well to medicine. Poor sleep may contribute to moody behavior or poor attention span. Dissociation may look like oppositional behavior or the child ignoring directions.

Take the time to involve the relevant caregivers, obtain adequate information from the homes and the school, and clarify symptoms and diagnosis.

In addition to evaluating for trauma and assessing sleep, use the “BOLDER” approach to assessment: T-MAY (Treatment of Maladaptive Aggression in Youth) Toolkit:

• Behavior: In what ways does the child exhibit aggression?
• Onset: When does it happen? What triggers it and why?
• Location: Where do the symptoms occur - home/school?
• Duration: How long does it last?
• Exacerbates: What makes it worse?
• Relief: What makes it better?

Maladaptive Aggression
Evidence-based treatment recommendations for maladaptive aggression in youth were published in the June 2012 issue of Pediatrics. The T-MAY guidelines are as follows:

• Treatment of maladaptive aggression in youth: CERT guidelines I. Engagement, assessment, and management. [Knapp: 2012]
• Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management. [Scotto: 2012]
• See Emotional Dysregulation: A Trauma-Informed Approach [Keeshin: 2021]

Also, see Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder [Zeanah: 2016].

Specialty Collaborations & Other Services

Psychiatry/Medication Management (see NV providers [49])

Assists with diagnosis of mental health disorders, symptom and medication management, particularly in complex cases with children who exhibit both medical and psychiatric disorders, and/or the coordination of mental health care.

General Counseling Services (see NV providers [209])

Evaluates for learning disabilities, autism, or developmental disorders. May provide individual or family therapy. Some psychologists have additional training in trauma-informed or trauma-focused treatment.

Neuropsychiatry/Neuropsychology (see NV providers [5])

Consider referral when a child has complex learning disorders associated with possible autism, intellectual disability, or brain injury.

Family Support Services (see NV providers [68])

Many community mental health centers provide case management or respite care for children in their programs. When a child is in the state’s custody, there are sometimes financial restrictions on whether the local mental health center or the child welfare system should provide these services.

Crisis Mental Health Care (see NV providers [34])

The Child Welfare system often contracts with specific providers for more intensive crisis and residential care and should be contacted when these services are needed.

Address safety and address local resources, crisis numbers, apps on Mobile Devices.

Sexual Assault Counseling (see NV providers [4])

Provides prevention, intervention, and treatment services for children and families.

Crisis/Respite Care (see NV providers [10])

Services to provide caregivers a break.

Transitions

Nearly 24,000 adolescents age out of the foster care system annually, usually when they turn 18. [Child: 2013] As they do so, they face serious challenges, including special health care needs that may not have been well-addressed when they were young and did not get better in adulthood. For most, lack of health care poses a substantial barrier. Even with health care, it can be difficult for aged-out foster youths to navigate the health care system or find medical practices that will accept their insurance.

Primary caregivers can help transition patients by working collaboratively with child welfare workers and assisting youth in:

• Gathering medical records that list past health provider names, major illnesses and conditions, medications taken, immunizations, and family medical history.
• Understanding their health issues, including safe medication use and the youth consent and assent process, and knowing when to seek treatment. Making Healthy Choices: Guide for Youth in Foster Care on Psychotropic Medications ( 9.7 MB) may help youth understand the use, limits, and alternatives to psychotropic medication.
• Understanding why their ongoing health care should be a priority.
• Finding a new adult primary care clinician as well as needed mental health, reproductive health, and dental services. See Finding Adult Health Care.
• Understanding the importance of health insurance and working with the caseworker to identify post-foster care insurance options.
• Identify emergency contacts and other individuals who support and encourage youth to be involved in making health care decisions.

As of 2014, the Patient Protection and Affordable Care Act makes youth aging out of foster care eligible for Medicaid coverage until age 26, regardless of income. This is retroactive for young adults who used to be in foster care. Other state-specific health coverage opportunities may include low-cost health and mental health services through community health centers, student health centers, or other resources. Health Services Locators provides a list of free or low-cost government services and insurance options, and Health Insurance Marketplace (HealthCare.gov) may be helpful to youth who no longer qualify for Medicaid.

During the numerous transitions that children in foster care experience - whether during reunification with parents or primary caregivers, adoption, guardianship, or emancipation from foster care, the primary care clinician can bring a whole-child perspective of health care for these youth and work with other caregivers to ensure comprehensive health services are maintained. [American: 2012] Helping Youth Transition to Adulthood: Guidance for Foster Parents (CWIG) ( 680 KB) may be helpful for foster parents involved in transitioning youth. Other resources include Transition Issues.

Specialty Collaborations & Other Services

Mentoring Programs (see NV providers [22])

Offers access to models of care and support in times of transition.

Vocational Education (see NV providers [45])

Provide career guidance and career coaching.

College Disability Centers (see NV providers [3])

Coordinate academic modifications, adjustments, auxiliary aids, adaptive technologies, and resources for academic and life planning.

Community & Continuing Education (see NV providers [28])

Teach academics, English as a Second Language, preparation for post-secondary training or education, and skills for success in employment.

Temporary Financial Assistance (see NV providers [10])

Provide emergency assistance, which helps homeless and low-income individuals and families work toward self-sufficiency.

Financial Education & Counseling (see NV providers [38])

Helps to increase the financial stability of low to moderate income households through obtaining a livable wage and learning basic financial principles.

Homeless Shelters (see NV providers [42])

Offers shelters, programs, and services that help homeless and low-income individuals and families work toward self-sufficiency.

Prescription Drug Patient Assistance Programs (see NV providers [40])

Provides funding for pharmaceutical needs.

Adolescent Health Transition Programs (see NV providers [2])

Provides support services usually include financial assistance, food stamps, child care, and eligibility to Medicaid, UPP, PCN, and CHIP. If unsure about State resources, collaborate with the child’s caseworker.

Dental Care Expense Assistance (see NV providers [3])

Offers free or low-cost emergency care, preventive (cleanings) and periodontal maintenance, restorative care (fillings, crowns, bridges), root canals, oral surgery, and dentures or partials.

Crisis Mental Health Care (see NV providers [34])

Provides immediate help for an array of mental health issues, including drug and alcohol abuse.

Community Based Organizations (see NV providers [24])

Offers representation for an array of social, legal, and cultural issues.

Educational Advocacy (see NV providers [5])

Provides services designed to increase the numbers of low-income students who graduate from high school and go on to attend college.

Outpatient Mental Health Care (see NV providers [45])

Provides mental health and substance abuse services.

Disability Rights Groups (see NV providers [16])

Offers education and support through facilitation of resources for specific health conditions.

On the Web

Helping Foster and Adoptive Families Cope with Trauma: A Guide for Pediatricians (AAP) ( 3.6 MB)
Designed to strengthen clinicians' abilities to identify traumatized children, educate families about toxic stress, and empower families to respond to children’s behavior in ways that acknowledge past traumas but promote the learning of adaptive reactions to stress; American Academy of Pediatrics.

Child Welfare Information Gateway (HHS)
Connects child welfare and related professionals to comprehensive resources; U.S. Department of Health & Human Services.

Child Welfare Guide for Behavioral and Mental Health Professionals (Child Welfare Information Gateway) ( 288 KB)
Six-pages focusing on cross-system partnerships(2019).

Fostering Health Online Resource Library (NCPeds)
Best Practice documents, videos, streamlined forms for exchanging information, and information about the American Academy of Pediatrics’ Standards of Care for the foster care population; North Carolina Pediatric Society (sign-in required).

California Evidence-Based Clearinghouse for Child Welfare
Easy access to research about screening, assessment tools, and treatment practices for children in foster care.

Council on Foster Care, Adoption, and Kinship Care (AAP)
Dedicated to improving the health and well-being of children and youth in foster care, kinship care, and those who have been adopted.; American Academy of Pediatrics.

Learning Center for Child and Adolescent Trauma (NCTSN)
Online courses and webinars focused on child welfare issues. See particularly the 0 to 6 Child Welfare series on the left menu; National Child Traumatic Stress Network.

National Scientific Council on the Developing Child
Information about toxic stress, the science of neglect, and much more; based at Harvard University.

Complex Trauma: Facts for Caregivers (NCTSN)
Helps parents and caregivers recognize the signs and symptoms of complex trauma and offers recommendations on how to help children heal; National Child Traumatic Stress Network.

Improving Outcomes for Youth Transitioning Out of Foster Care (Hawai'i Kids Count) ( 2.7 MB)
Strategies to improve outcomes for youth transitioning out of foster care, such as supporting educational success, providing employment and affordable housing opportunities, and ensuring access to health care.

How the Child Welfare System Works (Child Welfare Information Gateway) ( 789 KB)
Answers questions about the welfare system and what happens if abuse or neglect is reported or substantiated

Tackling Toxic Stress (Harvard University)
A series of articles that re-thinks services for children and families based on the science of early childhood development and an understanding of the consequences of adverse early experiences and toxic stress; Center on Developing Child.

Helpful Articles

Romanelli LH, Hoagwood KE, Kaplan SJ, Kemp SP, Hartman RL, Trupin C, Soto W, Pecora PJ, LaBarrie TL, Jensen PS.
Best practices for mental health in child welfare: parent support and youth empowerment guidelines.
Child Welfare. 2009;88(1):189-212. PubMed abstract
Summary of guidelines developed at the 2007 Best Practices for Mental Health Child Welfare Consensus Conference related to parent engagement and youth empowerment.

Szilagyi M.
The pediatric role in the care of children in foster and kinship care.
Pediatr Rev. 2012;33(11):496-507; quiz 508. PubMed abstract / Full Text
Describes the purpose and problems of foster care and the primary care clinician's supporting role.

Assessment Tools/Scales

M-CHAT-R/F Screen ( 1 KB)
Parent-completed questionnaire designed to identify children at risk of autism. An instrument available for free download in different languages for clinical, research, and educational purposes; © 2009 Diana Robins, Deborah Fein, & Marianne Barton.

Ages and Stages Questionnaire: Developmental (ASQ-3)
Parent-completed, age-specific questionnaires that screen for developmental delays in children between 1 month and 5½ years old; available for purchase.

ASQ:SE-2 (Ages and Stages Questionnaire: Social-Emotional)
A parent-completed series of 19 age-specific questionnaires screening communication, gross motor, fine motor, problem-solving, and personal adaptive skills. Results are in a pass/fail format for domains; available for purchase.

SEEK Parent Screening Questionnaire (PSQ-R)
Parent questionnaire that screens for child maltreatment and toxic stress using 15 yes/no questions. Scroll to bottom of the page for links to free to download in English, Chinese, Spanish, Swedish, and Vietnamese; from the University of Maryland, School of Medicine Department of Pediatrics.

Vanderbilt ADHD Parent Rating Scale ( 72 KB)
A 40-questions assessment designed to identify behavior problems and performance impairments at home; contains scoring information.

Patient Health Questionnaire (PHQ) Screeners
Free screening tools in many languages with scoring instructions to be used by clinicians to help detect mental health disorders. Select from right menu: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS, Brief PHQ, PHQ-4, PHQ-8.

SBIRT: Screening, Brief Intervention, and Referral to Treatment (SAMHSA)
Describes this evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs; Substance Abuse and Mental Health Services Administration.

Children’s Impact of Event Scale-13 (CRIES-13) ( 527 KB)
designed for use with children aged 8 years and above who are able to read independently. It consists of 4 items measuring Intrusion, 4 items measuring Avoidance and 5 items measuring Arousal – hence it is called the CRIES-13.

Care Processes & Protocols

Fostering Health: Standards of Care for Children in Foster Care
Developed by an AAP multidisciplinary panel of experts, Fostering Health has been designed for use by medical, mental health, and developmental health care professionals, as well as foster parents, social welfare agencies, members of the legal community, health insurance agencies, and policy makers. Standards of health care for children and adolescents in foster care are detailed in 10 chapters.

Traumatic Stress in Pediatric Patients Care Process Model ()
Best-practice recommendations (2020) for the prevention of childhood trauma as well as the identification and management of pediatric traumatic stress in primary care and children’s advocacy center settings. Includes screening and assessment tools. Developed through a collaboration of the Department of Pediatrics at the University of Utah and the Center for Safe and Healthy Families at Intermountain Healthcare’s Primary Children’s Hospital.

Medication Guides

Making Healthy Choices: Guide for Youth in Foster Care on Psychotropic Medications ( 9.7 MB)
Explores signs that indicate you may need help, knowing your rights and who can help, considering options, making decisions, and maintaining treatment; 28 pages. Created by youths who have experienced foster care and the U.S. Dept. of Health and Human Services.

Florida Best Practice Psychotherapeutic Medication Guidelines for Children and Adolescents (2022) ( 2.7 MB)
Recommendations for psychotherapeutic medication prescribing based on evidence and clinical consensus for a range of severe behavioral health symptoms and diagnoses; Florida Center for Behavioral Health.

Psychotropic Medication Utilization Parameters for Children and Youth in Foster Care (HHS) ( 534 KB)
General principles, role of primary care providers, medication use criteria, and tables with dosage and schedules; Health and Human Services (2021).

Psychotropic Medication Utilization Parameters for Children and Youth in Foster Care (Ohio Dept of Family Services) ( 437 KB)
Psychotropic medication practices, guidelines, ongoing monitoring, and evaluation (2014).

Toolkits

Primary Care Tools to Help Care for Children in Foster Care
Tools and resources aim to provide health care professionals with the necessary background, health assessment forms, forms to facilitate communication and collaboration between professionals, and other materials to help care for children and teens in foster care.

Toxic Stress Toolkit (AAP) ( 11.4 MB)
Information for primary care providers and their multidisciplinary teams serving young children in foster care in Rhode Island but relevant for all. Includes information about the negative health impacts of childhood adversity and toxic stress, screening tools for identifying those at highest risk for toxic stress and poor developmental and health outcomes, and an outline of resources; American Academy of Pediatrics, Rhode Island Chapter.

GLAD-PC: Guidelines for Adolescent Depression - Primary Care (REACH Institute)
Comprehensive set of guidelines addressing issues in screening, diagnosis, and treatment of depression in adolescents age 10-21 - includes an extensive toolkit; a PDF file from Resource for Advancing Children's Health.

Health Care Toolbox
Assessment, intervention, and training tools focused on helping children and families cope with illness and injury; Center for Pediatric Traumatic Stress at The Children's Hospital of Philadelphia.

Bright Futures in Practice: Mental Health—Volume II, Tool Kit
Comprehensive set of tools for clinicians and families; addresses mental health in various pediatric age groups; includes a variety of resources, checklists, intake and assessment forms, and patient education materials.

Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit (AAP)
Toolkit for pediatric care providers delivering comprehensive mental health care. Now in a new online format; available for a fee from American Academy of Pediatrics.

Other

Four Steps to Reframing Worksheet ( 94 KB)
A tool for children that helps break down problems into smaller steps. Adapted from the Surviving Cancer Competently Intervention Program – Newly Diagnosed (SCCIP-ND) manual; site developed by The Center for Pediatric Traumatic Stress and The Children’s Hospital of Philadelphia.

Traumatic Stress in Pediatric Patients Care Process Model ()
Best-practice recommendations (2020) for the prevention of childhood trauma as well as the identification and management of pediatric traumatic stress in primary care and children’s advocacy center settings. Includes screening and assessment tools. Developed through a collaboration of the Department of Pediatrics at the University of Utah and the Center for Safe and Healthy Families at Intermountain Healthcare’s Primary Children’s Hospital.

Information on the Web

HealthyChildren.org
The AAP parenting website priors foster care resources for parents, families, and caregivers.

Safe and Sound: Helping Children Who Have Experienced Trauma and Adversity
This series of resources is designed to help children who have experienced trauma and adversity, by helping their parents, caregivers, and other adults in their lives understand how that early trauma may have affected them. Each guide can be downloaded and shared to provide ideas for how to help children, and links to additional information and resources.

Child Welfare Information Gateway (HHS)
Connects child welfare and related professionals to comprehensive resources; U.S. Department of Health & Human Services.

Time for Reform: Aging Out and On Their Own (PEW Charitable Trusts)
Challenges of adolescents aging out of foster care systems with no permanent home or support.

Time for Reform: Preventing Youth From Aging Out On Their Own (PEW Charitable Trusts)
Recommendations for policy-level changes to enhance the success of those transitioning out of foster care.

Improving Outcomes for Youth Transitioning Out of Foster Care (Hawai'i Kids Count) ( 2.7 MB)
Strategies to improve outcomes for youth transitioning out of foster care, such as supporting educational success, providing employment and affordable housing opportunities, and ensuring access to health care.

Helping Youth Transition to Adulthood: Guidance for Foster Parents (CWIG) ( 680 KB)
Discusses the critical role of foster parents, laws, and programs supporting transitioning youth; Child Welfare Information Gateway.

National & Local Support

Foster Care Alumni of America
Connects the alumni community and works to transform policy and practice to help ensure opportunity for people in and from foster care.

Foster Care to Success--Aging Out Institute
Nonprofit organization with resources, programs, and research to help youth age out of foster care and into independence successfully.

Studies/Registries

Foster Care (clinicaltrials.gov)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.

Services for Patients & Families in Nevada (NV)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Administration on Children, Youth and Families, Childrens Bureau.
The AFCARS Report #26. Preliminary FY 2018 Estimates as of August 22, 2019 - No. 26.
Washington, DC: US Department of Health and Human Services; (2019) https://www.acf.hhs.gov/cb/report/afcars-report-26. Accessed on 1/28/2020.

American Academy of Pediatrics, Council on Foster Care, Adoption, and Kinship Care and Committee on Early Childhood.
Health care of youth aging out of foster care.
Pediatrics. 2012;130(6):1170-3. PubMed abstract / Full Text
Identifies challenges and recommendations for youth aging out of foster care.

American Psychiatric Association: DSM-5 Task Force.
Diagnostic and Statistical Manual of Mental Disorders.
Fifth ed. The American Psychiatric Publishing; 2013. http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425...

Baams L, Wilson BDM, Russell ST.
LGBTQ Youth in Unstable Housing and Foster Care.
Pediatrics. 2019;143(3). PubMed abstract / Full Text

Beal SJ, Greiner MV.
Children in nonparental care: health and social risks.
Pediatr Res. 2016;79(1-2):184-90. PubMed abstract

Chasnoff IJ, Wells AM, King L.
Misdiagnosis and missed diagnoses in foster and adopted children with prenatal alcohol exposure.
Pediatrics. 2015;135(2):264-70. PubMed abstract

Chernoff R, Combs-Orme T, Risley-Curtiss C, Heisler A.
Assessing the health status of children entering foster care.
Pediatrics. 1994;93(4):594-601. PubMed abstract

Child Trends.
Child maltreatment.
US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and families, Children's Bureau; (2019) https://www.childtrends.org/indicators/child-maltreatment.

Child Welfare Information Gateway.
Foster care statistics 2013.
U.S. Dept. of Health and Human Services; (2013) https://www.acf.hhs.gov/cb/research-data-technology/statistics-researc.... Accessed on 6/28/2021.
Report #21 available for 2013, and includes links through reports through 2019

Children's Bureau: An Office of the Administration for Children and Families.
Adoption & Foster Care Statistics.
U.S. Department of Health and Human Services; (2019) https://www.acf.hhs.gov/cb/research-data-technology/statistics-researc.... Accessed on Sept. 2021.

Christian CW.
The evaluation of suspected child physical abuse.
Pediatrics. 2015;135(5):e1337-54. PubMed abstract / Full Text

Council on Foster Care; adoption, and Kinship Care.
Health Care Issues for Children and Adolescents in Foster Care and Kinship Care.
Pediatrics. 2015;136(4):e1131-40. PubMed abstract / Full Text
Children and adolescents who enter foster care often do so with complicated and serious medical, mental health, developmental, oral health, and psychosocial problems rooted in their history of childhood trauma. Ideally, health care for this population is provided in a pediatric medical home by physicians who are familiar with the sequelae of childhood trauma and adversity. As youth with special health care needs, children and adolescents in foster care require more frequent monitoring of their health status, and pediatricians have a critical role in ensuring the well-being of children in out-of-home care through the provision of high-quality pediatric health services, health care coordination, and advocacy on their behalves. American Academy of Pediatrics Policy Statement.

Duffee J, Szilagyi M, Forkey H, Kelly ET.
Trauma-Informed Care in Child Health Systems.
Pediatrics. 2021;148(2). PubMed abstract / Full Text

Espeleta HC, Bakula DM, Sharkey CM, Reinink J, Cherry A, Lees J, Shropshire D, Mullins LL, Gillaspy SR.
Adapting Pediatric Medical Homes for Youth in Foster Care: Extensions of the American Academy of Pediatrics Guidelines.
Clin Pediatr (Phila). 2020;59(4-5):411-420. PubMed abstract

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS.
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
Am J Prev Med. 1998;14(4):245-58. PubMed abstract
Describes the relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Fraser JG, Noroña CR, Bartlett JD, Zhang J, Spinazzola J, Griffin JL, Montagna C, Todd M, Bodian R, Barto B.
Screening for Trauma Symptoms in Child Welfare-Involved Young Children: Findings from a Statewide Trauma-Informed Care Initiative.
J Child Adolesc Trauma. 2019;12(3):399-409. PubMed abstract / Full Text

Jim Casey Youth Opportunity Initiative.
Time for reform: aging out and on their own.
Pew Charitable Trusts. 2007. / http://www.pewtrusts.org/en/research-and-analysis/reports/2007/05/01/t...
Challenges of adolescents aging out of foster care systems with no permanent home or support; Pew Charitable Trusts.

Jones VF, Schulte EE, Waite D.
Pediatrician Guidance in Supporting Families of Children Who Are Adopted, Fostered, or in Kinship Care.
Pediatrics. 2020;146(6). PubMed abstract

Keeshin B, Forkey HC, Fouras G, MacMillan HL.
Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication.
Pediatrics. 2020. PubMed abstract
A clinical report that focuses on 2 key issues necessary for the care of maltreated children and adolescents in pediatric settings: trauma-informed assessments and the role of pharmacotherapy in maltreated children and adolescents.

Keeshin BR, Bryant BJ, Gargaro ER.
Emotional Dysregulation: A Trauma-Informed Approach.
Child Adolesc Psychiatr Clin N Am. 2021;30(2):375-387. PubMed abstract

Kerker BD, Zhang J, Nadeem E, Stein RE, Hurlburt MS, Heneghan A, Landsverk J, McCue Horwitz S.
Adverse Childhood Experiences and Mental Health, Chronic Medical Conditions, and Development in Young Children.
Acad Pediatr. 2015;15(5):510-7. PubMed abstract / Full Text

Knapp P, Chait A, Pappadopulos E, Crystal S, Jensen PS.
Treatment of maladaptive aggression in youth: CERT guidelines I. Engagement, assessment, and management.
Pediatrics. 2012;129(6):e1562-76. PubMed abstract / Full Text

Pierce MC, Kaczor K, Lorenz DJ, Bertocci G, Fingarson AK, Makoroff K, Berger RP, Bennett B, Magana J, Staley S, Ramaiah V, Fortin K, Currie M, Herman BE, Herr S, Hymel KP, Jenny C, Sheehan K, Zuckerbraun N, Hickey S, Meyers G, Leventhal JM.
Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics.
JAMA Netw Open. 2021;4(4):e215832. PubMed abstract / Full Text

Ringeisen H, Casanueva C, Urato M, Cross T.
Special health care needs among children in the child welfare system.
Pediatrics. 2008;122(1):e232-41. PubMed abstract
Presents levels of special health care need among children in the child welfare system and how these needs may affect children's functioning.

Romanelli LH, Hoagwood KE, Kaplan SJ, Kemp SP, Hartman RL, Trupin C, Soto W, Pecora PJ, LaBarrie TL, Jensen PS.
Best practices for mental health in child welfare: parent support and youth empowerment guidelines.
Child Welfare. 2009;88(1):189-212. PubMed abstract
Summary of guidelines developed at the 2007 Best Practices for Mental Health Child Welfare Consensus Conference related to parent engagement and youth empowerment.

Rosenberg R, Abbott S.
Examining data and trends in extended foster care.
Child Trends; (2019) https://www.childtrends.org/wp-content/uploads/2019/06/ExtendedFosterC....

Rubin DM, Alessandrini EA, Feudtner C, Localio AR, Hadley T.
Placement changes and emergency department visits in the first year of foster care.
Pediatrics. 2004;114(3):e354-60. PubMed abstract
Evaluates the temporal relationship between Emergency Dept. visits and placement changes and underscores the need for better health care management for foster children, particularly in the period after placement changes.

Scotto Rosato N, Correll CU, Pappadopulos E, Chait A, Crystal S, Jensen PS.
Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
Pediatrics. 2012;129(6):e1577-86. PubMed abstract / Full Text

Sepulveda K, Rosenberg R, Sunny S, Wilkins A.
Children and youth with special health care needs in foster care.
Child Trends; (2020) https://www.childtrends.org/publications/children-youth-special-health....

Shonkoff JP, Garner AS.
The lifelong effects of early childhood adversity and toxic stress.
Pediatrics. 2012;129(1):e232-46. PubMed abstract
Reaffirmed in 2016, this technical report presents a framework that illustrates how early experiences and environmental influences can leave a lasting signature on the genetic predispositions that affect emerging brain architecture and long-term health. The report also examines extensive evidence of the disruptive impacts of toxic stress.

Simms MD, Dubowitz H, Szilagyi MA.
Health care needs of children in the foster care system.
Pediatrics. 2000;106(4 Suppl):909-18. PubMed abstract

Stahmer AC, Leslie LK, Hurlburt M, Barth RP, Webb MB, Landsverk J, Zhang J.
Developmental and behavioral needs and service use for young children in child welfare.
Pediatrics. 2005;116(4):891-900. PubMed abstract / Full Text
Determines the level of developmental and behavioral need in young children entering child welfare (CW), estimates early intervention services use, and examines variation in need and service use based on age and level of involvement with CW.

Stein RE, Hurlburt MS, Heneghan AM, Zhang J, Rolls-Reutz J, Silver EJ, Fisher E, Landsverk J, Horwitz SM.
Chronic conditions among children investigated by child welfare: a national sample.
Pediatrics. 2013;131(3):455-62. PubMed abstract / Full Text

Stirling J Jr, Amaya-Jackson L, Amaya-Jackson L.
Understanding the behavioral and emotional consequences of child abuse.
Pediatrics. 2008;122(3):667-73. PubMed abstract / Full Text
Assists caregivers by helping them recognize the abused or neglected child's altered responses, formulate more effective coping strategies, and mobilize available community resources.

Strassburger Z.
Medical Decision Making for Youth in the Foster Care System, 49 J. Marshall L. Rev. 1103 (2016).
UIC Law Review. 2016; 49(4):53. https://repository.law.uic.edu/cgi/viewcontent.cgi?article=2706&contex...

Szilagyi M.
The pediatric role in the care of children in foster and kinship care.
Pediatr Rev. 2012;33(11):496-507; quiz 508. PubMed abstract / Full Text
Describes the purpose and problems of foster care and the primary care clinician's supporting role.

Szilagyi MA, Rosen DS, Rubin D, Zlotnik S.
Health Care Issues for Children and Adolescents in Foster Care and Kinship Care.
Pediatrics. 2015;136(4):e1142-66. PubMed abstract / Full Text

Turney K, Wildeman C.
Mental and Physical Health of Children in Foster Care.
Pediatrics. 2016;138(5). PubMed abstract

Winokur M, Holtan A, Batchelder KE.
Systematic Review of Kinship Care Effects on Safety, Permanency, and Well-Being Outcomes.
Res Soc Work Pract. 2018;28(1):19-32. PubMed abstract

Zeanah CH, Chesher T, Boris NW.
Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder.
J Am Acad Child Adolesc Psychiatry. 2016;55(11):990-1003. PubMed abstract