Acta Pædiatrica ISSN 0803-5253
REGULAR ARTICLE
Children in family foster care have greater health risks and less involvement in Child Health Services M K€ohler ([email protected])1, M Emmelin2, A Hjern3, M Rosvall1 €, Sweden 1.Department of Clinical Sciences, Lund University, Malmo €, Sweden 2.Department of Clinical Sciences, Social Medicine and Global Health, Lund University, Malmo 3.Department of Medicine, Karolinska Institutet and Centre for Health Equity Studies (CHESS), Stockholm, Sweden
Keywords Child Health Services, Children’s rights, Family foster care, Health records, Preschool children
ABSTRACT Aim: This study investigated the impact of being in family foster care on selected health
Correspondence €hler, MD, doctoral student, Department of M Ko Clinical Sciences, Lund University, Kunskapscentrum € €r barnh€alsov fo ard, Region Sk ane, Angelholmsgatan €, Sweden. 3 a, 205 02 Malmo Tel: +4640 623 94 43 | Email: [email protected]
Methods: Two groups of 100 children, born between 1992 and 2008, were studied
Received 18 August 2014; revised 10 November 2014; accepted 12 December 2014. DOI:10.1111/apa.12901
determinants and participation in Child Health Services (CHS). using data from Swedish Child Health Services for the preschool period up to the age of six. The first group had been in family foster care, and the controls, matched for age, sex and geographic location, had not. Descriptive statistics were used to describe differences in health determinants and participation in Child Health Services between the two groups. Results: The foster care group had higher health risks, with lower rates of breastfeeding and higher levels of parental smoking. They were less likely to have received immunisations and attended key nurse or physician visits and speech and vision screening. Missing data for the phenylketonuria test were more common in children in family foster care. Conclusion: Children in family foster care were exposed to more health risks than the control children and had lower participation in the universal child health programme during the preschool period. These results call for secure access to high-quality preventive health care for this particularly vulnerable group of children.
INTRODUCTION According to the Convention on the Rights of the Child, every child has the right to enjoy the “highest attainable standard of health”, to receive treatment and rehabilitation for illnesses and to have access to health services (1). But how does that work in practice for children in foster care, whose health and well-being are threatened for a number of reasons? International studies published in the 1990s reported that children in foster care had more health issues than other children, including high levels of mental health problems (2–4). More recent studies and reviews have confirmed both physical and mental health problems in children in foster care (5,6). There has been little research on the level of access that children in foster care have to health care, but those studies that have been carried out show incomplete immunisation and inadequate dental care (7). The Nordic countries have similar well-developed social welfare systems. Maternal and Child Health Services have become a natural part of families’ contacts with the healthcare system from pregnancy until school starts for children at six or seven-years-of-age. Child Health Services (CHS) offer preventive advice and promote child health care for newborns and their parents, including parental support, regular check-ups for health and development, immunisation and, if necessary, admittance to specialised or
508
inpatient care during the preschool period. Recommended CHS visits include the CHS nurse at the age of four weeks, the CHS physician at 10–12 months of age, speech screening at two-and-a-half to three-years-old, vision screening at five-years-of-age and immunisation according to the national programme. Participation in the CHS programme is voluntary and free of charge. It is estimated to reach 99% of the children in Sweden (8). It could be anticipated that these preventive services would diminish the differences in health problems between various groups of children. However, Nordic research has also shown that children in foster care have been worse off,
Key notes
This study looked at the differences in health risks and access to Swedish Child Health Services between children in family foster care and other children. Children in family foster care had higher health risks and lower participation in preventive Child Health Services during the preschool period. Systems need to be developed, and implemented, to close the gap between this particularly vulnerable group of children and other children and to ensure their well-being.
©2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 508–513
€hler et al. Ko
starting with poorer neonatal health at birth (9). Higher levels of disabilities and physical health problems are found in children who are currently, or have been in, foster care (10,11). Psychiatric problems and child psychiatric diagnoses, such as autism, attention-deficit hyperactivity disorder and delayed development, are more frequent, as are suicide attempts, suicide and higher mortality rates (12–15). Research on the health of children in foster care has, until now, mostly focused on children in their teens, and knowledge about younger children is lacking. To find out more about the health of children in foster care, and their use of health care, a study examined data on both preschool and school children up to 16-years-old who were in the € in 2008. This family foster care system in the city of Malmo showed that 20% of the school children had health problems during their first year in school and 40% had contact with child psychiatric care services (16). In this study, we used this data to investigate selected health determinants and participation in Child Health Services during the preschool period, from birth to six-years-old, comparing children in family foster care with other children.
POPULATION AND METHODS It is estimated that about 1% of children and young people under the age of 20 in Sweden were placed in out-of-home € , which is the care at some time during 2012 (17). In Malmo third biggest city in Sweden and has about 300 000 inhabitants, 223 children aged between birth and 16years-of-age were placed in family foster care by Social € for at least three months on Services in the city of Malmo 15 September 2008. The parents who still had custody of the children were initially contacted by mail to give their informed consent for us to access their child’s health records from the Child Health Services (CHS), School Health Services, Dental Health Services and Social Services. Some parents needed to be contacted by phone and, in a very small number of cases, by a home visit. Children who were older than 15 were contacted through a personal letter. This process was handled by a research assistant who had no previous professional or personal relationship with the parents or the children. In this study, we only used information from the CHS and Social Services. We received consent to include 121 children, including eight who had settled in Sweden after they started school and had no health records from the CHS. We managed to locate the CHS health records for 100 of the remaining 113 children, either from Child Health Centres (CHC) or from the regional archive. However, 15 of these were incomplete due to missing pages. For the control group, we used 100 anonymous age- and gender-matched health records from children registered in the CHS in € during their preschool period and who were not, Malmo and had never been, in family foster care on 15 September 2008. The controls were children born in the same year and month as the foster children and the same gender. They were randomly selected from CHS health records in the regional archive. Ethical approval was received from the
Foster care and health
Ethics Board in Gothenburg on 15 December 2008 (Dnr: 633-08), with additional approval given on 26 November 2013 (Dnr: T946-13). We analysed the CHS health records to get information about health determinants and participation in the CHS. At the time, they were in traditional paper form and should have followed the child if he or she changed CHC because they moved. The health records contained notes made by nurses and physicians about family demographics, the child’s health and the health care they received, including some data about the child’s birth. At the first visit, the nurse should have registered certain socio-demographic, psychosocial and medical data to get a broad understanding of the child’s starting point and possible needs. These included the following: the child’s name, sex, birth date, country of birth, parents’ country of birth, occupations of both parents, residential address, siblings and half siblings, psychosocial problems and hereditary health conditions. The health records also had designated areas for routine notes and specific health visits. The selected health determinants in this study included exclusive and partial breastfeeding at child age of one week and four months and parental smoking at four and 8 months. Participation in the CHS programme was based on data about the PKU test which provides routine newborn screening for rare but treatable metabolic disorders, speech and vision screening, immunisations and key visits to nurses and physicians. To get valid data, certain age ranges were chosen for each visit/screening, for example five years plus or minus 1 month for vision screening. Socio-demographic factors included the child’s and the parents’ ages, the child’s sex, number of siblings and the child’s country of birth. The age when the child was first placed in family foster care, and the reason for the placement, was gathered from the social care records. We have referred to children in family foster care throughout the paper, to differentiate them from the control group, even though some of them were not placed in family foster care before the age of six. Statistics Means, frequencies and standard deviations for sociodemographic factors were analysed for the cases and controls. Proportions of health determinants, such as breastfeeding and parental smoking, and healthcare participation in the phenylketonuria (PKU) test, seeing a CHS nurse at 4 weeks of age, visiting a CHS physician at 10 to 12-months-of-age, speech screening at two-and-a-half to three years of age, vision screening and immunisations at the age of five were estimated. Furthermore, referrals from the CHS to various specialists during the preschool period were analysed. Chi-square test and t-test were used to estimate levels of significance. Children with incomplete information on specific indicators were excluded from that part of the analysis. All statistical analyses were made with the aid of SPSS 20.0 (SPSS Inc, Chicago, IL, USA).
©2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 508–513
509
€hler et al. Ko
Foster care and health
RESULTS The study population consisted of 100 family foster care children and 100 age, sex and geographically matched controls born between 1992 and 2008. The mean age in both groups in September 2008 was 10-years-of-age, and boys accounted for 55% in both groups (Table 1). Most of the children 97% of the foster care group and 99% of the control group – were born in Sweden. The mean age of the parents was similar in the two groups, with the family foster child group mothers being slightly younger than the control mothers, at 28 and 29, and both sets of fathers being 32. Information on parental occupation was missing for 72% of the mothers and 75% of the fathers for children in family foster care compared to those not in family foster care where 29% of mothers’ and 33% of fathers’ occupations were missing (data not shown). Some 10% of the foster care group children had five or more siblings and half siblings, compared to none in the control group. The vast majority (70%) of the family foster care children were placed in care before they were seven-years-old, and the median age at the first out-of-home placement was three-and-a-half years. The most common reasons for placement were parental alcohol or drug abuse (35%), neglect (30%), parental mental health problems (13%), parental health issues (7%) and/or child physical abuse (6%). At least one parent had died in 25% of the foster care cases (data not shown). Low birthweight (
REGULAR ARTICLE
Children in family foster care have greater health risks and less involvement in Child Health Services M K€ohler ([email protected])1, M Emmelin2, A Hjern3, M Rosvall1 €, Sweden 1.Department of Clinical Sciences, Lund University, Malmo €, Sweden 2.Department of Clinical Sciences, Social Medicine and Global Health, Lund University, Malmo 3.Department of Medicine, Karolinska Institutet and Centre for Health Equity Studies (CHESS), Stockholm, Sweden
Keywords Child Health Services, Children’s rights, Family foster care, Health records, Preschool children
ABSTRACT Aim: This study investigated the impact of being in family foster care on selected health
Correspondence €hler, MD, doctoral student, Department of M Ko Clinical Sciences, Lund University, Kunskapscentrum € €r barnh€alsov fo ard, Region Sk ane, Angelholmsgatan €, Sweden. 3 a, 205 02 Malmo Tel: +4640 623 94 43 | Email: [email protected]
Methods: Two groups of 100 children, born between 1992 and 2008, were studied
Received 18 August 2014; revised 10 November 2014; accepted 12 December 2014. DOI:10.1111/apa.12901
determinants and participation in Child Health Services (CHS). using data from Swedish Child Health Services for the preschool period up to the age of six. The first group had been in family foster care, and the controls, matched for age, sex and geographic location, had not. Descriptive statistics were used to describe differences in health determinants and participation in Child Health Services between the two groups. Results: The foster care group had higher health risks, with lower rates of breastfeeding and higher levels of parental smoking. They were less likely to have received immunisations and attended key nurse or physician visits and speech and vision screening. Missing data for the phenylketonuria test were more common in children in family foster care. Conclusion: Children in family foster care were exposed to more health risks than the control children and had lower participation in the universal child health programme during the preschool period. These results call for secure access to high-quality preventive health care for this particularly vulnerable group of children.
INTRODUCTION According to the Convention on the Rights of the Child, every child has the right to enjoy the “highest attainable standard of health”, to receive treatment and rehabilitation for illnesses and to have access to health services (1). But how does that work in practice for children in foster care, whose health and well-being are threatened for a number of reasons? International studies published in the 1990s reported that children in foster care had more health issues than other children, including high levels of mental health problems (2–4). More recent studies and reviews have confirmed both physical and mental health problems in children in foster care (5,6). There has been little research on the level of access that children in foster care have to health care, but those studies that have been carried out show incomplete immunisation and inadequate dental care (7). The Nordic countries have similar well-developed social welfare systems. Maternal and Child Health Services have become a natural part of families’ contacts with the healthcare system from pregnancy until school starts for children at six or seven-years-of-age. Child Health Services (CHS) offer preventive advice and promote child health care for newborns and their parents, including parental support, regular check-ups for health and development, immunisation and, if necessary, admittance to specialised or
508
inpatient care during the preschool period. Recommended CHS visits include the CHS nurse at the age of four weeks, the CHS physician at 10–12 months of age, speech screening at two-and-a-half to three-years-old, vision screening at five-years-of-age and immunisation according to the national programme. Participation in the CHS programme is voluntary and free of charge. It is estimated to reach 99% of the children in Sweden (8). It could be anticipated that these preventive services would diminish the differences in health problems between various groups of children. However, Nordic research has also shown that children in foster care have been worse off,
Key notes
This study looked at the differences in health risks and access to Swedish Child Health Services between children in family foster care and other children. Children in family foster care had higher health risks and lower participation in preventive Child Health Services during the preschool period. Systems need to be developed, and implemented, to close the gap between this particularly vulnerable group of children and other children and to ensure their well-being.
©2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 508–513
€hler et al. Ko
starting with poorer neonatal health at birth (9). Higher levels of disabilities and physical health problems are found in children who are currently, or have been in, foster care (10,11). Psychiatric problems and child psychiatric diagnoses, such as autism, attention-deficit hyperactivity disorder and delayed development, are more frequent, as are suicide attempts, suicide and higher mortality rates (12–15). Research on the health of children in foster care has, until now, mostly focused on children in their teens, and knowledge about younger children is lacking. To find out more about the health of children in foster care, and their use of health care, a study examined data on both preschool and school children up to 16-years-old who were in the € in 2008. This family foster care system in the city of Malmo showed that 20% of the school children had health problems during their first year in school and 40% had contact with child psychiatric care services (16). In this study, we used this data to investigate selected health determinants and participation in Child Health Services during the preschool period, from birth to six-years-old, comparing children in family foster care with other children.
POPULATION AND METHODS It is estimated that about 1% of children and young people under the age of 20 in Sweden were placed in out-of-home € , which is the care at some time during 2012 (17). In Malmo third biggest city in Sweden and has about 300 000 inhabitants, 223 children aged between birth and 16years-of-age were placed in family foster care by Social € for at least three months on Services in the city of Malmo 15 September 2008. The parents who still had custody of the children were initially contacted by mail to give their informed consent for us to access their child’s health records from the Child Health Services (CHS), School Health Services, Dental Health Services and Social Services. Some parents needed to be contacted by phone and, in a very small number of cases, by a home visit. Children who were older than 15 were contacted through a personal letter. This process was handled by a research assistant who had no previous professional or personal relationship with the parents or the children. In this study, we only used information from the CHS and Social Services. We received consent to include 121 children, including eight who had settled in Sweden after they started school and had no health records from the CHS. We managed to locate the CHS health records for 100 of the remaining 113 children, either from Child Health Centres (CHC) or from the regional archive. However, 15 of these were incomplete due to missing pages. For the control group, we used 100 anonymous age- and gender-matched health records from children registered in the CHS in € during their preschool period and who were not, Malmo and had never been, in family foster care on 15 September 2008. The controls were children born in the same year and month as the foster children and the same gender. They were randomly selected from CHS health records in the regional archive. Ethical approval was received from the
Foster care and health
Ethics Board in Gothenburg on 15 December 2008 (Dnr: 633-08), with additional approval given on 26 November 2013 (Dnr: T946-13). We analysed the CHS health records to get information about health determinants and participation in the CHS. At the time, they were in traditional paper form and should have followed the child if he or she changed CHC because they moved. The health records contained notes made by nurses and physicians about family demographics, the child’s health and the health care they received, including some data about the child’s birth. At the first visit, the nurse should have registered certain socio-demographic, psychosocial and medical data to get a broad understanding of the child’s starting point and possible needs. These included the following: the child’s name, sex, birth date, country of birth, parents’ country of birth, occupations of both parents, residential address, siblings and half siblings, psychosocial problems and hereditary health conditions. The health records also had designated areas for routine notes and specific health visits. The selected health determinants in this study included exclusive and partial breastfeeding at child age of one week and four months and parental smoking at four and 8 months. Participation in the CHS programme was based on data about the PKU test which provides routine newborn screening for rare but treatable metabolic disorders, speech and vision screening, immunisations and key visits to nurses and physicians. To get valid data, certain age ranges were chosen for each visit/screening, for example five years plus or minus 1 month for vision screening. Socio-demographic factors included the child’s and the parents’ ages, the child’s sex, number of siblings and the child’s country of birth. The age when the child was first placed in family foster care, and the reason for the placement, was gathered from the social care records. We have referred to children in family foster care throughout the paper, to differentiate them from the control group, even though some of them were not placed in family foster care before the age of six. Statistics Means, frequencies and standard deviations for sociodemographic factors were analysed for the cases and controls. Proportions of health determinants, such as breastfeeding and parental smoking, and healthcare participation in the phenylketonuria (PKU) test, seeing a CHS nurse at 4 weeks of age, visiting a CHS physician at 10 to 12-months-of-age, speech screening at two-and-a-half to three years of age, vision screening and immunisations at the age of five were estimated. Furthermore, referrals from the CHS to various specialists during the preschool period were analysed. Chi-square test and t-test were used to estimate levels of significance. Children with incomplete information on specific indicators were excluded from that part of the analysis. All statistical analyses were made with the aid of SPSS 20.0 (SPSS Inc, Chicago, IL, USA).
©2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 508–513
509
€hler et al. Ko
Foster care and health
RESULTS The study population consisted of 100 family foster care children and 100 age, sex and geographically matched controls born between 1992 and 2008. The mean age in both groups in September 2008 was 10-years-of-age, and boys accounted for 55% in both groups (Table 1). Most of the children 97% of the foster care group and 99% of the control group – were born in Sweden. The mean age of the parents was similar in the two groups, with the family foster child group mothers being slightly younger than the control mothers, at 28 and 29, and both sets of fathers being 32. Information on parental occupation was missing for 72% of the mothers and 75% of the fathers for children in family foster care compared to those not in family foster care where 29% of mothers’ and 33% of fathers’ occupations were missing (data not shown). Some 10% of the foster care group children had five or more siblings and half siblings, compared to none in the control group. The vast majority (70%) of the family foster care children were placed in care before they were seven-years-old, and the median age at the first out-of-home placement was three-and-a-half years. The most common reasons for placement were parental alcohol or drug abuse (35%), neglect (30%), parental mental health problems (13%), parental health issues (7%) and/or child physical abuse (6%). At least one parent had died in 25% of the foster care cases (data not shown). Low birthweight (
