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
Dec 26, 2015
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
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 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