Pediatric Approach to Trauma Treatment and Resilience-A Novel Relationship-Based Curriculum and Approach to Train Pediatric Professionals to Provide Trauma-Informed Care.

Information and techniques from evidence-based, trauma-informed mental health treatments, resilience and parenting literature and supporting evidence from neuroscience were adapted to provide pediatricians a practical approach and tools to promote resilience and respond to trauma symptoms.

Parental perspectives of screening for adverse childhood experiences in pediatric primary care.

INTRODUCTION: Pediatricians recognize a need to mitigate the negative impact that adverse childhood experiences (ACEs) can have on health and development. However, ACEs screening and interventions in primary care pediatrics may be inhibited by concerns about parental perceptions. We assessed parent perspectives of screening for ACEs in the pediatric primary care setting, to understand their views on the potential impact of their ACEs on their parenting and to identify opportunities for pediatric anticipatory guidance. METHOD: We used purposive sampling to recruit parents of children <6 years receiving care at an urban, pediatric clinic. Semistructured questions guided 1:1 interviews that were later coded by multiple researchers to verify reliability. A thematic framework approach guided analysis and identified main themes and subthemes. RESULTS: We reached thematic saturation after 15 parent interviews, which consistently revealed 3 interrelated themes. First, parents strongly supported ACEs screening as a bridge to needed services, and they recommended using a trauma-sensitive, person-centered approach in pediatric practices. Second, parents understood the intergenerational impact of ACEs and expressed a desire to break the cycle of adversity. Finally, parents saw their child's pediatrician as a potential change-agent who could provide support to meet their parenting goals. DISCUSSION: Parents want to discuss their ACEs and receive help and guidance from pediatricians. Furthermore, they perceive their child's pediatrician as having an important role to play in meeting their parenting goals. It is important to ensure that pediatricians have the training, skills and familiarity with available resources to meet parental expectations. (PsycINFO Database Record

Health Care Issues for Children and Adolescents in Foster Care and Kinship Care.

Children and adolescents involved with child welfare, especially those who are removed from their family of origin and placed in out-of-home care, often present with complex and serious physical, mental health, developmental, and psychosocial problems rooted in childhood adversity and trauma. As such, they are designated as children with special health care needs. There are many barriers to providing high-quality comprehensive health care services to children and adolescents whose lives are characterized by transience and uncertainty. 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 in the context of a medical home, and health care coordination and advocacy on their behalf. This technical report supports the policy statement of the same title.

Trends in child protection and out-of-home care.

BACKGROUND: Over the past decades, increased knowledge about childhood abuse and trauma have prompted changes in child welfare policy, and practice that may have affected the out-of-home (OOH) care population. However, little is known about recent national trends in child maltreatment, OOH placement, or characteristics of children in OOH care. The objective of this study was to examine trends in child maltreatment and characteristics of children in OOH care. METHODS: We analyzed 2 federal administrative databases to identify and characterize US children who were maltreated (National Child Abuse and Neglect Data System) or in OOH care (Adoption and Foster Care Analysis and Reporting System). We assessed trends between 2000 and 2010. RESULTS: The number of suspected maltreatment cases increased 17% from 2000 to 2010, yet the number of substantiated cases decreased 7% and the number of children in OOH care decreased 25%. Despite the decrease in OOH placements, we found a 19% increase in the number of children who entered OOH care because of maltreatment (vs other causes), a 36% increase in the number of children with multiple (vs single) types of maltreatment, and a 60% increase in the number of children in OOH care identified as emotionally disturbed. CONCLUSIONS: From 2000 to 2010, fewer suspected cases of maltreatment were substantiated, despite increased investigations, and fewer maltreated children were placed in OOH care. These changes may have led to a smaller but more complex OOH care population with substantial previous trauma and emotional problems.

Identification of social-emotional problems among young children in foster care.

BACKGROUND: Little is known about how best to implement behavioral screening recommendations in practice, especially for children in foster care, who are at risk for having social-emotional problems. Two validated screening tools are recommended for use with young children: the Ages and Stages Questionnaire: Social Emotional (ASQ-SE) identifies emotional problems, and the Ages and Stages Questionnaire (ASQ) identifies general developmental delays in five domains, including personal-social problems. The current study examined: (1) whether systematic use of a social-emotional screening tool improves the detection rate of social-emotional problems, compared to reliance on clinical judgment; (2) the relative effectiveness of two validated instruments to screen for social-emotional problems; and (3) the patterns of social-emotional problems among children in foster care. METHODS: We used retrospective chart review of children in foster care ages 6 months to 5.5 years: 192 children before and 159 after screening implementation, to measure detection rates for social-emotional problems among children. The ASQ-SE and the ASQ were used in multivariable logistic regression analyses to examine associations between children with social-emotional problems. RESULTS: Use of the screening tool identified 24% of the children as having a social-emotional problem, while provider surveillance detected 4%. We identified significantly more children with social-emotional problems using the ASQ-SE than using the ASQ, and agreement between the instruments ranged from 56% to 75%, when data were stratified by age group. Multivariable modeling showed that preschool children were more likely to have a social-emotional problem than toddlers and infants (aOR = 3.4, 95% CI = 1.1-10.8). CONCLUSIONS: Systematic screening using the ASQ-SE increased the detection rate for social-emotional problems among young children in foster care, compared to provider surveillance and the ASQ. A specific social-emotional screening tool appears to detect children with psychosocial concerns who would not be detected with a broader developmental screening tool.

Foster care issues in general pediatrics.

PURPOSE OF REVIEW: This study highlights recent publications on foster care, focusing on concerns for the general pediatrician, including risk factors for foster care placement, outcomes of foster care, healthcare and screening standards, and developmental and mental health problems. RECENT FINDINGS: Many children and youth in foster care have been exposed to complex trauma prior to foster care placement. As clinicians gain a greater understanding of the life experiences of children in foster care, more preventive and supportive efforts can be implemented in the clinical setting, specifically around health and mental health issues. Enhanced awareness of the issues would enable healthcare professionals to advocate effectively for the needs of children in the child welfare system. To address the complex health and socio-emotional needs of children in foster care, several healthcare models and innovative programs for the care of children in foster care have been developed. This literature review for the past year suggests a lack in program evaluation of these efforts. SUMMARY: Pediatricians have the opportunity to address physical and mental health issues for children in foster care, and can provide anticipatory guidance to foster and biological parents who bring their children for evaluation.

Learning difficulties among children separated from a parent.

OBJECTIVE: To study the relationship between experiencing separation from parents and having learning difficulties among children in a community-based sample. METHODS: In 2003, parents of children entering kindergarten in the city of Rochester completed a survey assessing the child's social background, medical history, and behavioral profile. Children separated from parents for >1 month were compared with those who had never been away for >1 month on 4 validated developmental measures (range, 1-4): a learning scale, an expressive language scale, a preliteracy scale, and a speech scale. Bivariate analyses and multivariate logistic regression analyses were used to determine associations between separation from parents and learning difficulties. RESULTS: Among the 1619 children, 18% had been separated from a parent for >1 month at least once (11% once, 7% > or =2 times). Separated children scored worse compared with those without separations on learning (3.14 vs 3.28, P = .001) and preliteracy (2.21 vs 2.35, P = .03). Higher rates of learning difficulties (26.7% vs 16.7%, P < .001) and preliteracy problems (25.9% vs 18.7%, P = .01) were noted among those who had been separated versus those who had not. In multivariable modeling, separation was associated with learning problems (adjusted odds ratio, 1.71; 95% confidence interval, 1.18-2.49) and preliteracy problems (adjusted odds ratio, 1.46; 95% confidence interval, 1.04-2.05) when adjusted for demographic, medical, and social factors. CONCLUSIONS: Urban children who have experienced separation from a parent may have more learning difficulties at entrance to kindergarten. Screening and intervention practices to remedy these challenges may better equip such young children to succeed when they enter school.

Factors associated with chronic conditions among children in foster care.

The population of children in foster care is rapidly growing. Previous local and state-level analyses have measured the prevalence of chronic conditions among such children to be from 44%-82%. The study objective was to identify factors associated with chronic conditions among a nationally representative sample of children in foster care for one year. The authors analyzed data from The National Survey of Child and Adolescent Well-Being (NSCAW), Wave 1, the first national dataset of children in the child welfare system. In regression analysis, factors significantly associated with having a chronic condition included: child age under 2 years, caregiver race/ethnicity other than Hispanic, and relatively few household members. Discussion includes consideration of chronic conditions in this high-risk population.

Emergency department utilization by children in foster care.

OBJECTIVE: To examine emergency department (ED) utilization of children in foster care using nationally representative data. METHODS: Cross-sectional analysis of the National Survey of Child and Adolescent Well-Being, Wave 1, which provided data for children ages 1 to 14 years in foster care for 1 year between October 1999 and December 2000. We identified children as having used the ED based upon foster parent responses to the question, "In the last 12 months, has your child gone to an emergency room or urgent care center (UCC) for an illness or injury?" We examined child and family demographic variables that were associated with having used the ED. RESULTS: The sample included 559 children in foster care. Thirty-one percent (95% confidence interval = 26%, 36%) of foster children had visited the ED or UCC in the past 12 months. Multivariate logistic regression analysis revealed that out of all children in foster care, children who had a chronic condition, children of younger age, and children with younger foster caregivers were significantly more likely to have used the ED. CONCLUSION: A sizeable proportion of children in foster care use the ED, and subgroups of these children have particularly high rates of ED use. An important component of providing a medical home for children in foster care should involve coordination of care around ED visits for this vulnerable group of children.