Most children enter out-of-home care in a poor state of health. For many, placement in a stable environment with competent foster caregivers can be a positive, nurturing, and healing experience. Over time, the children may show significant improvements in physical, emotional, and intellectual development [Kent 1976; Fanshel and Shinn 1978; Palmer 1979; White and Benedict 1986]. The out-of-home care system, however, is often unable to respond appropriately to the needs of children with multiple chronic or complex health problems. Although children's health often plays a significant role in determining the course and/or success of social service interventions, it has not been a primary focus of the child welfare field. With rare exceptions, child welfare agencies lack specific policies on health care to guide workers and have few staff members with sufficient training in matters of health [Halfon and Klee 1991]. Furthermore, administrative structures to ensure that children's health needs are identified and treated are generally nonexistent.
State child welfare agencies are increasingly being held legally liable to ensure that the complex physical, emotional, and developmental needs of the children are met while in state care and custody [Halfon and Klee 1987]. To meet these expanded responsibilities for children's health, child welfare agencies must often increase their personnel and financial allocations, change their basic service goals and policies, and in some cases, create new organizational structures and delivery mechanisms. This is not an easy task, and agencies experience difficulties as they attempt to incorporate ideas and beliefs that are not part of the normal social work approach, and forge new models of service delivery that represent an amalgam of social work and health care practices and procedures. Ultimately, the key to successfully meeting these challenges will lie in the ability of child welfare and health care professionals to work together effectively to meet the needs of these children and their families.
This paper discusses some significant issues that complicate the delivery of health care services to children in the out-of-home care system, reviews recommended health care standards, and suggests key areas for additional research and program development. We begin with a brief discussion of the unique health care needs of children in care and why these needs are difficult to meet. We then turn to the normative standards developed over the past decade to focus on service delivery from the perspective of individual children and families (individual level), agencies and interagency procedures (systems level), and policies (policy level).
The Health Care Needs of Children in Out-of-Home Care
It is not surprising that children entering out-of-home care have complex physical, emotional, and developmental problems. Several studies have documented that children in care have high rates of chronic medical, mental health, and developmental problems [Schor 1982; Kavaler and Swire 1983; Moffatt et al. 1985; Hochstadt et al. 1987; Simms 1989]. These children frequently have multiple health problems affecting many aspects of functioning. Most often they come from very poor, minority, single-parent families, whose members suffer from high rates of mental illness, substance abuse, homelessness, and chronic physical disability. Many parents of these children were themselves abused and neglected, and their capacity to provide for their children has been further compromised by impediments to educational and intellectual achievement. Additionally, the children often come from the most impoverished urban areas that have the highest rates of crime, violence, and drug abuse.
The chronic neglect and abuse that most often result in out-of-home placement often includes neglect of basic preventive and primary health care. In fact, the relationship between health problems and placement is a complex one. …