By ELIZABETH GARONE
Sue Parada is running out of display space on the walls of her South St. Louis home. She's hung a photo of every one of the foster children who have been in her household over the past 43 years, and there have been a lot of them: 205 at last count. The children have stayed anywhere from a few hours to a year.
Both Parada and her late husband, Ivan, had medical backgrounds: she as a lab and X-ray technician and he as a lab technician and pharmacist. Social service agencies thought of the couple when they had to place a foster child with significant medical needs.
This 2012 portrait shows Ivan and Sue Parada, who recently had been lauded as "Angels in Adoption" by the Congressional Coalition on Adoption Institute. In the background is a photo gallery of foster children they welcomed into their St. Louis home. Sue Parada continues her work as a foster parent following her husband's death in 2014. Lisa Johnston/© St. Louis Review
Most children are placed in the foster care system because of abuse, neglect or abandonment and many have not had regular, routine pediatric care. Some children are removed from the custody of a parent or guardian abruptly, under extremely stressful circumstances, having suffered cumulative emotional trauma. (See sidebar.) They may arrive at their foster homes with nothing but the clothes on their backs.
Parada says that up until a few years ago, when SSM Health Cardinal Glennon Children's Hospital opened its clinic for foster children, it was not uncommon for a social services worker to offer little to no medical information when they placed a child in her care. It was scary, says Parada, not knowing whether a child had a serious allergy, or was subject to seizures.
Earl and Roxanne Carr have fostered more than 40 children. Roxanne Carr says the medical assessment provided by a specialty clinic at SSM Health Cardinal Glennon Children's Hospital "has been a huge blessing and a lifesaver" in that work. The couple is shown here with the four siblings they are in the final stages of adopting.
Like Parada, Roxanne Carr is a seasoned foster parent. She and her husband Earl have fostered more than 40 children. Carr says when the family started as licensed foster care providers in 2004, they too braced for medical surprises. They might learn of a child's asthma when he or she began to wheeze. "You didn't know anything about the child," she says.
But both Parada and Carr say that situation began to change for the better three years ago. In 2015, clinicians and social workers at St. Louis' SSM Health Cardinal Glennon Children's Hospital teamed up with the Missouri Department of Social Services' Children's Division to launch Fostering Healthy Children, a program that provides medical assessment for children in the foster care systems in St. Louis city and county.
The Fostering Healthy Children clinic conducts initial exams for children from birth to age 12 who are entering the foster care system. And it provides the comprehensive follow-up exams that are required by the state within 30 days of a new foster care placement. It also makes referrals for specialty medical and mental health services and follows up to make sure the children are receiving care through a primary care provider. (Foster children age 13 and older are referred to a specialty clinic at Washington University in St. Louis.)
While Fostering Healthy Children does not have the capacity or funding to provide primary care beyond the initial sets of medical and mental health exams, its staff work to ensure that the children will have a primary care provider, says Maggie McVey Vogt, one of two full-time nurses who work with the program. (There is also a part-time nurse.) The clinic sends the medical history and health information it compiles to the new primary care provider.
Detective work
For many foster parents, just finding a pediatrician who will treat the children in their care can present problems. "Providing quality medical care to foster children is not easy," says Dr. Timothy Kutz, the SLUCare pediatrician who conceived of and heads up Fostering Healthy Children. "Many (foster children) arrive at physicians' offices without any information regarding their prior health. This leaves the physician guessing as to what that child's issues are." This is a void that the Fostering Healthy Children clinic set out to fill.
McVey Vogt
Fostering Healthy Children's comprehensive assessments include a search for all paper and electronic medical records, state immunization records and school district records. This information is consolidated into the electronic health record at SSM Health Cardinal Glennon Children's Hospital.
The approach to health care history is more intensive than the one taken for children residing with adults who know them well, according to Kutz. Typically, when a child is in a stable home environment, the parent is offering health details to the doctor. But when a foster child is placed with a new family, the foster parents need to rely on clinicians for that medical information.
"Our team spends a considerable amount of time gathering past health information. A team member sits down with the new caretakers and provides a comprehensive review of that child's health," he says. "We gather additional information from interviews of the new caretakers and assessments of the children" and create a plan to address identified issues.
Continuity of care
Instability can define the life of a foster child. McVey Vogt says some children have had three or more placements by the time they come in for an assessment at the clinic. "Each time their placement changes, the primary care physician usually changes, too," McVey Vogt says. "Without a common thread like our clinic, these kids would fall into the gaps every time they move to a new foster home. We track the child's placement changes to the best of our ability and continue to forward any known medical history to the new PCPs," she says.
The comprehensive medical record can help ensure continuity of care for a child with a chronic condition such as asthma. Most children in foster care have at least one chronic medical problem, Kutz says.
The rate of chronic health conditions is 1.5 times greater for children involved in the child welfare system than for the general population, according to a 2013 study in the journal Pediatrics. Depending on the measure used, roughly one-third to one-half of all children investigated were reported by their caregivers to have a chronic health condition, according to the study.
Kutz
McVey Vogt adds that, luckily, many of the Fostering Healthy Children clinic's patients are referred to SSM providers, including the primary care clinic at Cardinal Glennon Children's Hospital so their medical history is readily available.
As part of its medical case management, staff at the Fostering Healthy Children clinic review Medicaid's billing records and note what medical services have been billed for a particular child. They check with primary care providers to ask if there are any developmental delays or concerns. Staff review medical records periodically and follow up with the families to see if they need any additional medical resources. They also check in with new primary care providers when a child changes placement. If exams are missed, staff contact foster parents, caseworkers, pediatricians, and even sometimes the deputy juvenile officers at the court, to re-educate them about the schedule of exams, says Donna Erickson, Fostering Healthy Children's clinic coordinator.
Scaling up
Parada says that knowing the health history of a newly arrived foster child is a relief. When there is a health concern, "I can call day or night and they can help get me what I need," she says.
Adds Carr, "This program has been a huge blessing and a lifesaver."
Fostering Healthy Children began as a pilot to determine if comprehensive health assessments, medical case management and focused education of foster parents and community providers would be a more effective way of addressing the medical needs of kids in foster care, explains Erickson.
After the initial grant ended in 2017, the state and hospital agreed that there was benefit to the program and they have jointly underwritten the ongoing costs. Erickson says the intent always has been to share what has been learned with other entities in the hope that, eventually, all foster kids in Missouri will benefit from similar programs.
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Post-traumatic stress disorder is common in kids in the foster care system
Many children who enter the foster care system have had little stability and extraordinary stress in their young lives. They may have witnessed or suffered abuse, gone hungry or watched their parents on drug-fueled benders. It is not surprising then that many foster children suffer from post-traumatic stress disorder and may need specialized therapy to recover, according to Maggie McVey Vogt, a nurse with the Fostering Healthy Children clinic at SSM Health Cardinal Glennon Children's Hospital in St. Louis.
"These children have developing brains and the trauma that they experience disrupts normal development," she says. In their medical assessments of children in the foster care system, clinic staff frequently identify behavior issues, developmental delays, and a need for ongoing trauma-focused therapy, says McVey Vogt. "All of the kids who come to our clinic are treated through a 'trauma-focused lens.' All of their treatment is based on the premise that they have suffered some degree of trauma in their past.
"The earlier these children are able to access trauma-informed therapy services, the quicker the healing might begin, allowing them to resume typical neurological and emotional development," she says.
As part of a comprehensive assessment, all children ages 4 and up receive a mental health evaluation conducted by the program's psychologist Dr. Jaimi Ramsey, who specializes in trauma. She makes mental health referrals and provides foster families and caseworkers with resources to help them know how to access appropriate mental health services in the community, according to McVey Vogt.
Donna Erickson, Fostering Healthy Children's clinical coordinator, says foster children may be teased at school by kids who demand to know about their "real" parents. Teachers may not pay as much attention to a foster child they think will stay in their classroom for a short time before moving to another school. Erickson says this type of marginalization or rejection can occur in a pediatric practice too because of the labor involved in opening a chart for a patient who is likely to be transient.
McVey Vogt says to counter the hurt and stigmatization, the staff of the Fostering Healthy Children clinic treat their patients with extra care and attention "to help them heal and return to the tasks of a healthy childhood."
— ELIZABETH GARONE
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