How do we measure health in children 0-5 years in Out of Home care? Margaret GOLDFINCH, Diana BARNETT, Stacey BLACK, Holly DONNELLY, Santhini KUMARAN,

How do we measure health in children 0-5 years in Out of Home care?

Margaret GOLDFINCH, Diana BARNETT, Stacey BLACK, Holly DONNELLY, Santhini KUMARAN, Anna STACHURSKA, Romina TUCKER

The Children’s Hospital Westmead and Redbank House1

What health needs?• Children in OOHC are a vulnerable “at-risk”

group.• This group are likely to have poorer physical,

mental and developmental health than their peers. (RACP, 2006)• 45% if all children in care in NSW in June 2010

were 0-6 years old.

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• impacts on placement stability, (Horwitz et al, 2000; Rubin et al 2004)

• poor academic achievement• increased risk of mental health

problems in adolescence • poor attachment in relationships as

adults. (Leslie et al, 2005)

Neglecting the Needs of Children in the Care System

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National Clinical Assessment Framework (March 2011)

- Developmental history- Speech, language and communication- Motor development- Cognitive development- Sensory

Psychosocial and Mental Health

- History- Mental Health- Behavioural- Emotional development- Social competence- Development of identity

Developmental

- Physical health history- Physical examination and assessment- Oral Health assessment- Health literacy

Physical

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Why is this work so challenging?

• Children/P in OOHC have complex needs• Change of placements/ carers• Change of case workers• Limited medical history • Information lost/ not handed over• No consistent advocate for the child• Contact with birth parents• Kinship/ relative carers- FOI issues

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SCHN - OOHC clinic model• Comprehensive Multidisciplinary assessments for 0- 5

year olds already in care.• Model based on health, developmental and

psychosocial needs identified in literature.• Partnership between ACC, Redbank House and SCHN

(Randwick and Westmead)• MD team- Paediatrician, Social Worker/Psychologist,

Audiologist, Orthoptist, SP, and OT. Senior Psychologist to provide supervision

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OOHC Clinic AssessmentBackground info:• Caseworker makes health referral providing

details of background, health information and reasons for entry into care• Questionnaires sent to carers (ASQ3, ASQSE,

CBCL, SDQ, PSI-SF)• Teachers- pre-school questionnaire (designed

by clinic, four areas- motor performance, pre-academic skills, language skills, social and behaviour)

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0-5 yr old OOHC Clinic Assessment

Developmental hxASQ3 reviewPlay assessmentClinical observations during appointmentFormal assessment by OT and/or Speech pathologist if indicatedPreschool quest’aire

Psychosocial and Mental Health

Developmental

Medical examination

Audiology Asst

Vision and eye screen

Physical

Play assessmentInterview with carerObservation of child/ carer interaction/ relationship and attachmentAddress any concerns raised by caseworkerReview preschool FB

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Questionnaires• ASQ3 (Ages and Stages 3)- parent completed,

developmental screener, covers communication, gross motor, fine motor, problem-solving, personal-social

• CBCL (Child Behaviour Checklist)- assess a child’s behavioural, emotional and social problems and competencies from their parent or carers point of view

• PSI (Parenting Stress Index)- measures stress experienced by a carer in caring for a particular child, due to the specific features of the child or the nature of interactions with them

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• ASQ SE (Ages & Stages Questionnaire – Social/Emotional ) monitors a child’s development in the areas of self-regulation, compliance, communication, adaptive, autonomy, affect and interaction with people.

• SDQ (Strengths & Difficulties Questionnaire) - focuses on whether a child has difficulty with emotions, concentration, behaviour or getting along with others. • Preschool/ School Questionnaire

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Referral Information – Search for “Red Flags”• Reasons for Removal

• Exposure to DV, abuse, AOD,

• Placement History• Age at entry to care, number of placements, any placement

breakdowns

• Medical history• Genetic vulnerability, perinatal insults, neonatal abstinence

syndrome, is child on medications

• Any Concerns from carer, child care, agencies• Behaviour (tantrums, aggression),illness, developmental, social

skills• Inconsistencies between reports of child’s behaviour in

different settings (eg carer and childcare)

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Paediatric AssessmentMedical history Sources of information: • FaCS (pre assessment - health questionnaire), blue book, ACIR, carer, • Medical records (neonatal and other discharge summaries, copy of medical letters), • Reports (AOD centre, psychologists, preschool)

Focus on: prenatal exposure to alcohol/ illicit drugs, prenatal exposure to Hepatitis B or C, perinatal complications, family history of developmental /intellectual disabilities, genetics, early growth parameters and how it change over time,immunization status, medications, allergies and current health concerns

Physical examination: Focus on: growth, nutritional state, physical evidence of prenatal exposure to alcohol, dysmorphic features & thorough systemic examination ie. respiratory, cardiovascular, neurological, etc…

Allied health• Audiology clinic: hearing testing• Eye clinic: vision and eye screening

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Psychosocial Assessment• Any emotional or behavioral concerns? –eg tantrums,

aggression, “spacing out”, sexualized behaviour, regulation problems

• Sleeping, eating, settling, comfort seeking, play, peer relations, sibling issues

• How these are managed by carer• How does child relate within the foster family?• Response to contact w biological family• Developmental history (if available)• Social and communication skills• Review preschool feedback

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Semi structured Play Assessment Modified from Crowell Assessment (1988)

Approx 20 minutes• Play as you normally would• Follow child’s lead ( play skills collaboration,

reciprocity, enjoyment)• Ask child to pack up ( compliance ,

cooperation)• Bubbles (enjoyment, collaboration)• Puzzles (skills, attention, concentration,

scaffolding, collaboration)• Brief separation (3 mins) • Reunion• Reflection 15

ObservationsCarer - sensitivity, structuring , intrusiveness, hostility - Availability as a secure base Child -responsiveness, involvement, initiative, regulation, cuing/miscuing carer, imagination - Use of carer as a secure baseDyad – comfort, tension and regulation, joint attention, reciprocity, enjoyment, mutualityMulti D team Observations – developmental/play skills, fine motor, communication, multiple views of same behaviour or interaction -> rich discussion

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Multi D Team Discussion

HM Report

Medical Investigations/ Specialist referrals

Further Psych Assessment or

follow up support

Early Intervnention services

Referral to Speech or Occ

Therapy

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Steven• 4 year old boy, removed at 24mths

• Two short term placements and has been in current placement for last 18 months

• Birth parents have intellectual disabilities, two siblings with developmental delay

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• History of neglect , A & D during pregnancy and parental IV drug use (unknown Hep C status)

• Starting school next year, attends pre-school 3 days/week

• Pre-school worries about his learning, fine motor skills and outbursts of aggression towards peers

• Monthly contact with birth family. Carer reports difficulties with his behaviour before/after contact visit

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Questionnaires:

• ASQ- III concerns in communication, fine motor, problem solving and personal social skills

• ASQ- SE and CBCL, SDQ- indicate problems with aggression, emotion regulation, concentration and sleep

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Psychosocial• Carer struggling with his behaviour at home• Stephen has difficulty following directions (observed)• Puzzle skills poor for his age. Carer not able to help him

persist and had trouble encouraging him to pack up• Quickly moved between play objects but didn’t

persistently engage with any activity to developmental expectations • Steven didn’t acknowledge return of carer after

separation, or use her as a ”secure base” during the interview

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Physical/ Medical• No medical history prior to this placement• Growth - 3rd centile for height and weight (genetic? early

neglect or organic ? no previous measurements)• Mild facial dysmorphic features (no biological relatives to

compare with) • Dental decay• Sleep difficulties- snores• Hearing assessment: mild conductive hearing loss bilaterally• Unremarkable rest of examination

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Developmental• Pre-school teacher indicated difficulties at pre-

school, poor fine motor skills and inability to follow instructions

• Clinic observations and screening questionnaires indicate need for formal developmental assessment

• Referred to OT and Speech Pathology within clinic

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OT Assessment• Completed M-FUN. Scores on fine motor

component and visual motor component were below average.• General observations showed some inattention

during activities.• Scattering of abilities and experience across

different skills eg. Unable to cut along a line, poor drawing skills but aged appropriate self care skills • Carer not having good knowledge of what is

appropriate for their age

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Speech Assessment• Language skills assessed using the CELF-

Preschool-2.• Difficulties with following directions

accurately.• Expressive language testing revealed

reduced vocabulary and short length of utterance for age.• Short attention span noted

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Health Management Plan (Recommendations)• Continued stability in placement• Support for carer around understanding and managing

behavioural presentation• OT &SP referral with Early Intervention • Liaison with Department of Education and Communities (DEC)

school planning• Psychometric assessment prior to school

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• ENT referral• Routine oral health follow-up• ?Genetics referral and investigation for DD• Link with Paediatrician and GP - to monitor health, growth and

developmental progress • Caseworker to compile all health information and have access to

this on file

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Strengths of Multidisc Team Assessment

• Combined interview :- • More than one perspective on behaviour, symptoms or

observations which appear contradictory in interview• Allows medical assessment longer time frame • Raises the profile of importance of developmental and

psychosocial issues in health management of foster children• Each clinician learns from other disciplines and improves

assessment eg evolution of the play assessment• Less clinic visits for carer and child 28

• Second occasion and location of assessment by OT & SP• Picked up consistencies in child’s presentation and

interaction w carer

• Subsequent team discussion • richer and more balanced view of overlapping and

complex symptoms and the child’s needs

• Combined HMP and Report• Broader view of child’s wellbeing• Greater access to/knowledge about services for

follow-up

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Difficulties we Encountered• Some carers/families uncomfortable or suspicious of

emotional or psychosocial assessment• Large time allocation needed for collating

information and writing comprehensive report (considerable time)• Single interview – sometimes needed time for

discussion and reflection after interview before giving feedback• Background history and information difficult to find

due to fragmentation• Different carers have different needs or expectations

from the assessment process

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Questions??

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Reference:Australian Institute of Health and Welfare (2010)

Chambers, M., Saunders, A., New, B. Williams, C. & Stachurska, A. (2010). Assessment of children coming into care: Processes, pitfalls and partnerships. Clinical Child Psychology and Psychiatry. 15(4): 511-526.

Community Services Annual Report (2010)

Horwitz, S., Owens P., & Simms, M. (2000). Specialized assessments for children in foster care. Journal of Pediatrics. 106: 59–66.

Kaltner, M. & Rissel, K. (2011). Health of Australian children in out-of-home care: Needs and carer recognition. Journal of Paediatrics and Child Health. 47: 122-126.

Leslie, L., Gordon, J., Lambros, K., Premji, K., Peoples, J. & Gist K. (2005). Addressing the developmental and mental health needs of young children in foster care. Journal of Developmental and Behavioral Pediatrics. 26: 40–51.

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Nathanson, D. & Tzioumi, D. (2007). Health needs of Australian children living in out-of-home-care. Journal of Paediatrics and Child Health. 43: 695-699.

Osborn, Alexandra and Delfabbro, Paul H. (2006) Research Article 4: An Analysis of the Social Background and Placement History of Children with Multiple and Complex Needs in Australian Out-of-home Care. Communities, Children and Families Australia. 1 (1): 33-42.

Rubin D, Alessandrini E, Feudtner C, Mandell D, Localio A & Hadley T. (2004). Placement stability and mental health costs for children in foster care. Journal of Pediatrics. 113: 1336–41.

Reynolds, S. (2008). Kari Clinic. KARI Aboriginal Resources Inc. SNAICC News

Tarren-Sweeney, M. & Hazell, P. (2006) Mental health of children in foster and kinship care in New South wales, Australia. Journal of Paediatrics and Child Health. 42: 89-97.

The Royal Australasian College of Physicians. (2006). Health of children in "out-of-home" care. 1-28.

Townsend, A. & Shelley, K. (2008). Validating an instrument for assessing workforce collaboration. Community College Journal of Research and Practice, 32 101-112.

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