Mark D. Simms

Foster care: an update.

OBJECTIVE To inform child and adolescent psychiatrists about the almost 500,000 children now residing in the American foster care system. This overview surveys the pediatric, developmental, and psychiatric needs of these children. METHOD Child and adolescent psychiatrists, pediatricians, a child welfare researcher, a social worker, and a psychologist developed a consensus paper from their experience with child welfare and a review of the literature in their respective fields. RESULTS Being in foster care is a defining experience in these childrens lives. They are at risk in myriad ways: for instance, being poor, having chronic health deficits, experiencing the trauma of abuse and neglect, and suffering from a gamut of emotional challenges. Evolutionary developments in foster care such as therapeutic foster homes, kinship care, and changes in Medicaid funding will continue to alter the system. CONCLUSIONS Foster children are a huge reservoir of unmet pediatric and psychiatric needs; research on them is spotty at best. It is hoped that child and adolescent psychiatrists will meet the challenges these youngsters present and will advocate for them.

Specialized assessments for children in foster care.

Objective. To investigate the differences in health problems identified and health services received by children newly entering foster care who participated in a comprehensive multidisciplinary program, compared with children newly entering foster care who received customary community-based services. Methods. Using a 2-group quasiexperimental design, 120 young children entering foster care were enrolled in a multidisciplinary intervention program (n = 62) or were followed by customary care providers (n = 58). An interview with the foster parent; a complete medical examination; and a battery of developmental, psychological, speech/language, and motor assessments were completed for each child at baseline. Children in both groups participated in follow-up assessments at 6 and 12 months. Results. No significant differences between the 2 groups existed in medical, educational, developmental, or mental health problems identified by foster mothers. However, children in the intervention group were more likely to be identified with developmental (56.5% vs 8.6%) and mental health problems (37.1% vs 13.8%) by providers than children in the comparison group. Children in the intervention group were also more likely to be referred for health services at baseline (71.0% vs 43.1%) and receive follow-up care at 6 and 12 months of age than children in the comparison group. Conclusions. Findings indicate that community providers identify medical and educational needs but do not recognize developmental and mental health needs of young children newly entering foster care. The discrepancies in the number of recommended services and follow-up care between the 2 groups make a case for the establishment of specialized services for children entering out-of-home care.

Impact of developmental problems on young children's exits from foster care

Children entering foster care are often described as having multiple problems, although there are surprisingly few comprehensive baseline descriptions of children as they enter care. Further, few studies have examined the interactions among baseline characteristics, physical and mental health problems, and their joint influence on the likelihood that a child will remain in care. The purpose of this study was to investigate the relationship of physical and developmental problems identified shortly after the children entered substitute care to the likelihood of their remaining in care. Data for these analyses came from 272 children (ages 1 month to 7 years) seen at the Foster Care Clinic in Waterbury, Connecticut, between November 1985 and December 1989. All children received a complete physical health assessment and developmental screening upon entry into care. The outcome variable, childrens placement status as of September 1990, was confirmed through the Social Services Agencys records. Results indicate that children in foster care commonly showed developmental delays (53%). Further, those who were older at entry into care and nonwhite and who had developmental problems identified were 1.93 times more likely to remain in foster care. Given these findings, early comprehensive assessment for children entering foster care is strongly recommended. J Dev Behav Pediatr 15:105–110, 1994. Index terms: developmental problems, foster care.

The foster care clinic: a community program to identify treatment needs of children in foster care

A community-based multiagency and multidisciplinary clinic was developed to perform comprehensive evaluations of preschool children in foster care. One hundred thirteen children, ages 1 month to 6 years old, were seen during the first 2 years. Forty-seven percent of the children were known to the social service agency from birth; however, the mean age at placement was 19 months. Fifty-seven percent of the children were in their first foster home at the time of their initial evaluation, but 17% had already been placed in three or more homes. Behavioral problems were found in 39% of the children, and chronic medical problems in 35%. Sixty-one percent of the children were delayed in one or more portions of the developmental assessment. Developmental delay was associated with older age. Sixty percent of the children with developmental delays were not involved in any community educational or therapeutic program, although they had been in foster care for a mean of 6 months. Because of the high mobility of this population, continuity of care by social workers, foster parents, and physicians is hard to achieve. The evaluation model developed by the clinic appears to facilitate the identification of children in need of additional services, enhances cooperation between various community agencies, and provides a constant site for monitoring the status and progress of children in foster care.

Factors associated with toilet training in the 1990s.

CONTEXT Few studies have systematically evaluated the factors influencing toilet training in children with normal development. OBJECTIVES To determine those child, parent, and environmental factors associated with toilet training completion, focusing on the influence of the childs temperament and development. DESIGN AND SETTING Cross-sectional descriptive study of normal children, ages 15-42 months, attending 1 of 4 pediatric clinics in Milwaukee in 1995 and 1996. METHODS Demographics for child, parents, and household were surveyed. Temperament was assessed using the Toddler Temperament Scale and the Behavioral Style Questionnaire. Child development was measured using the Bayley Scales of Infant Development II. MAIN OUTCOME MEASURE Toilet training status was by parental report and was categorized as not trained, not currently training, in training, or training complete. RESULTS The study population included 496 children, comprising 219 that had not started training, 70 that were not currently training, 148 that were in training, and 59 that were completely trained. The ages at which 50% of the children were predicted to be toilet trained were 35 and 39 months for girls and boys, respectively. In the multivariate regression model, statistically significant factors best predicting toilet training completion were older age, non-Caucasian race, female gender, and single parenthood. Temperament, development, maternal employment, or use of day care were not statistically significant factors. CONCLUSION Innate factors such as older age, non-Caucasian race, and female gender are the best predictors of completing toilet training (rather than a childs temperament and developmental stage). Day care and maternal employment appear to be unimportant variables. Parents should not be discouraged, because children are completing toilet training at older ages. Research is needed to discover why single parents are more successful at toilet training.

Foster children and the foster care system, Part II: Impact on the child.

These three programs represent efforts to solve some of the common clinical problems encountered in the care of foster children. Building on existing community resources, they create new services tailored to the specific needs of the individuals. Together, they form a continuum of services for foster and natural families; as children are identified in the Foster Care Clinic, they are referred for help to community service providers. Supporting visitation through the FRP can smooth the childs adjustment to placement and facilitate eventual return home or another permanent plan. The information from each program complements the other, and a rich and very valuable picture of the children which emerges can assist the agency and the court to make decisions based on assessments of the individual strengths and needs of the children and their families. The medical passport provides a critical link between the agency and physicians to ensure that the children receive the highest standard of health care possible.

Foster children and the foster care system, part I: History and legal structure

Introduction Foster care is widely perceived to be a harmful experience for children. Yet for many it may be the most significant intervention that society can provide to ensure them safety and nurture. Unfortunately, popular glorification of “the virtues of family life” and reluctance to interfere with “the sanctity of the family” have meant that many children who are known to be at high risk for abuse and neglect, or who have in fact been victims of such abuse and neglect, are allowed to remain in harmful circumstances, under “state supervision,” for fear of disrupting their families. There are many paradoxes in foster care. For example, although children in placement miss their biologic families intensely, in most cases the beneficial effects of removal from an abusive, neglectful environment outweigh the traumatic effects of separation. Similarly, although visits with their parents are a source of great stress for many foster children, visits are highly correlated with eventual reunification of the family. Finally, despite the fact that children’s basic emotional and developmental needs are frequently unrecognized, misunderstood, and untreated, there is convincing evidence that most foster children show wide-ranging improvements in cognitive and social development during placement. Foster care involves complex interaction among

Autism, Language Disorder, and Social (Pragmatic) Communication Disorder: DSM-V and Differential Diagnoses.

• Based on strong research evidence (1), the prevalence of autism spectrum disorders (ASDs) has increased over the past decade, with a 2010 prevalence of 1:68 (1.5%) in children age 8 years. • Based on some research evidence as well as consensus (3), the most recent revision of the American Psychiatric Associations Diagnostic and Statistical Manual (DSM-V) identifies two core dimensions for the diagnosis of ASD: social (social communication and social interaction) and nonsocial (restricted, repetitive patterns of behaviors, interests, or activities). • Based on some research evidence as well as consensus (3) (31) (32) (33) (34), DSM-V identifies social pragmatic communication disorder (SPCD) as a dissociable dimension of language and communication ability that affects how individuals use language for social exchanges. SPCD is often found in children with language impairments and children with attention-deficit/hyperactivity disorder and other genetic/neurologic conditions. • Based on strong research evidence (2) (26) (27) (28), childhood language disorders affect 7.4% of kindergarteners, and 50% to 80% of these children experience persistent language, academic, and social-emotional difficulties into their adult years, despite having normal nonverbal cognitive abilities. • Based primarily on consensus due to lack of relevant clinical studies, differential diagnosis of autism and language disorders may require a multidisciplinary evaluation that takes into account a child’s overall development, including cognitive, communication, and social abilities. Monitoring the response to appropriate interventions and trajectory of development over time may improve the accuracy of diagnosis, especially in very young children.

When Autistic Behavior Suggests a Disease Other than Classic Autism

Most neurodevelopmental disorders are defined by their clinical symptoms and many disorders share common features. Recently there has been an increase in the number of children diagnosed with autism spectrum disorder, although concerns have been raised about the accuracy of the reported prevalence rates. This article reviews the essential features of autism spectrum disorder and describes other conditions that may include similar symptoms that may be misdiagnosed as autism spectrum disorder (primary communication disorders, anxiety disorders, attachment disorders, intellectual disability, vision and hearing impairment, and normal variations). An approach to differential diagnosis is discussed with particular attention to evaluation of young children.

An Interprofessional Team Approach to the Differential Diagnosis of Children with Language Disorders

The ability to communicate effectively with others is central to childrens development. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences. Physical anomalies, neurologic and genetic disorder, cognitive and intellectual disabilities, and emotional disturbances may affect speech and language development. Communication disorders may be misdiagnosed as intellectual impairment or autism. Interdisciplinary evaluation should include speech and language assessment, physical and neurologic status, cognitive and emotional profile, and family and social history. This article describes assessment and reviews common pediatric communication disorders.