Description of the condition
Substantial numbers of children worldwide are receiving out of home care. In the United States (US) in September 2010, 408,000 children were receiving out of home care (AFCARS data 2010); in England in March 2011, 65,520 children (DfE SFR 2011); in Scotland in July 2010, 15,892 children (National Statistics Publication for Scotland 2011); in Wales in March 2011, 5419 children (National Statistics 2011); in Australia in June 2011, 37,648 children (AIHW 2012) and in Norway in December 2009, 6603 children and young people (from birth to17 years of age) (Statistics Norway 2011). Most children are in out of home care programmes as a result of substantiated maltreatment, such as neglect, physical abuse, sexual abuse and/or emotional abuse. Other reasons for placement in out of home care include inability of the family to cope, parental illness, death and homelessness (AAP 2002; DfE SFR 2011; National Statistics 2011). Children in out of home care may be in foster care placements, kinship placements or other alternative care placements such as residential care homes. Worldwide, studies have consistently shown that children in out of home care have increased rates of physical, developmental, mental health and behavioural needs compared with their peers. The reasons for this are multi-layered and include increased likelihood of exposure to child abuse and neglect, disadvantage and poverty, poor antenatal care and poor parental health, especially mental health problems, and substance misuse (AAP 2002; RACP 2006).
Physical problems experienced by children in out of home care include acute and chronic health problems, impaired vision and hearing, poor oral and dental health, and lower rates of immunisation uptake. Ninety per cent of North American children in out of home care were found to have an abnormality in one or more body system; 15% failed a hearing screening test, 25% did not pass a vision screen, and the children were both lighter and shorter than their peers (Chernoff 1994). During initial placement, a North American study found that 27% of children had an upper respiratory illness, 21% had skin conditions, 12% had poor oral and dental health, and approximately one-third failed a vision screen (Takayama 1998). A longitudinal study from the United Kingdom (UK) of children in out of home care found that 52% had a health problem that required outpatient treatment and 26% had more than one problem requiring treatment (Skuse 2001). In this study, it was estimated that 15% of children were likely to have required treatment from a specialist (Skuse 2001). An Australian study in an out of home care clinic situated in a tertiary paediatric hospital found that only 3% of children who were assessed had no health problems, 30% failed a vision screen, and 28% failed a hearing test. Concern arose regarding abnormal growth and infection for 14% and 12%, respectively, and 24% of children had incomplete immunisation records (Nathanson 2007).
High rates of developmental, behavioural, and emotional problems are seen in children in out of home care. In the US, more than one-fifth of children younger than five years of age failed a developmental screening test (Chernoff 1994;Takayama 1998), and mental health screening of children older than three years of age found that almost 15% had suicidal ideation, 7% had homicidal ideation, and 36% had a history of behavioural problems (Chernoff 1994). In Australia, 60% failed a developmental screening test and 54% were identified as having behavioural problems (Nathanson 2007). Another Australian study that examined the mental health of children in court-ordered out of home care placements, using two standardised carer-report questionnaires, found that the children had high levels of poor mental health and socialisation: The range and severity of problems were reported to be similar to those of US clinic-referred groups (Tarren-Sweeney 2006). Difficulties included high rates of social problems, distorted thought patterns, attention difficulties, rule breaking or delinquent behaviour, and aggression. Roughly one-third were found to have some degree of age-inappropriate sexual behaviour, and many were reported to show behaviour suggestive of insecure relationships (Tarren-Sweeney 2006. Fifty-four per cent of Aboriginal children in out of home care in Australia were found to have a speech and language delay, and one-third had fine motor skill delay; 64% of school-aged children were found to have educational problems (Raman 2007).
Description of the intervention
It is recognised that children in out of home care have increased rates of physical, developmental, mental health, and behavioural needs compared with their peers; therefore clinical practice policy guidelines have been introduced in some countries to assist with the management of these needs. These guidelines have emphasised the need for comprehensive paediatric assessments to actively screen for problems associated with this group (AAP 2002; RACP 2006; DoH 2009). Before guidelines were introduced, 'usual care' for children in out of home care meant that health assessments would occur only when specific problems were suspected, and these assessments may not have been comprehensive but might have focused on a specific health issue instead.
Current clinical practice policy guidelines from the US, the UK, and Australia indicate that all children in out of home care should receive a comprehensive paediatric assessment upon entering care (within 30 days) and should undergo follow-up assessments (AAP 2002; RACP 2006; DoH 2009). Assessments should be comprehensive, and should be performed by staff experienced in meeting needs and managing care for children living in out of home care. They should include a careful history, during which available information on the child is collated: medical assessment of the child's physical health and growth, developmental and mental health screening, the formulation of a healthcare plan, and identification of a healthcare co-ordinator. In some countries, registration in a national scheme is a prerequisite for accessing public health services, including services provided for children in public care.
No standardised or universally accepted model has been used to deliver comprehensive paediatric assessments for this vulnerable group of children. Published data are based on differing assessment models, for example, multi-disciplinary assessment in a designated community-based foster care clinic setting (McCue Horwitz 2000), multi-disciplinary assessment at a health screening clinic for children in out of home care at a tertiary paediatric hospital Child Protection Unit (Nathanson 2007), and multi-disciplinary assessment in a paediatric outpatient department setting at a university hospital (Blatt 1997). Other ways in which models may differ include the choice of staff members who perform the assessments (e.g. individual paediatrician, nurse practitioner, multi-disciplinary team); the assessment location (e.g. hospital-based service, community health setting, foster agency setting) and the clinic structure itself (e.g. specialist out of home care clinics (seamless care) compared with standard outpatient clinics or private rooms). Assessment facilities may differ in the degree to which they can provide follow-up and case management.
How the intervention might work
The American Academy of Pediatrics has reported that the healthcare of children in out of home care is often compromised, and most do not receive a comprehensive developmental or psychological assessment at any time during their placement. Factors responsible for this include inadequate funding, poor planning, lack of access, prolonged waits for services, poor service co-ordination, and poor communication (AAP 2002). Barriers to adequate intervention for children in out of home care also include lack of permanency plans for these children, multiple placements with resultant changes in key people involved in the care of the child (e.g. carer, caseworker, local doctor, school teacher), and inadequate transfer of information when the placement changes; often there is ambiguity as to who is responsible for co-ordinating healthcare services for the child (AAP 2002; RACP 2006).
Children in out of home care are likely to benefit from comprehensive paediatric assessments because these assessments identify problems and areas of need for a given child (which otherwise may not have been noted), facilitate care through appropriate referrals (Hill 2003), and identify a healthcare co-ordinator for the child (RACP 2006). Although different models of comprehensive paediatric assessment have been proposed, it is unclear which models are most effective. Studies in the US have shown that uptake of comprehensive paediatric assessments for children in out of home care has been poor, and that although assessments have been helpful in identifying health problems and needs, little action is being taken on the basis of recommendations that have been put forth (AAP 2002).
Why it is important to do this review
To date, no systematic review has examined the effectiveness of comprehensive paediatric assessments for children entering out of home care in identifying physical health, developmental, mental and behavioural problems, and facilitating access to appropriate interventions.
No standardised model is available for the delivery of comprehensive paediatric assessments for children entering out of home care, and the published data reflect this. Providing comprehensive paediatric assessments is a complex intervention, and it is very unlikely that it has been studied in the format of a randomised trial. Therefore it is important for the authors of this systematic review to look at both randomised and non-randomised study design types when assessing the effectiveness of the intervention, and to systematically report the findings and limitations of available study design types.