Dental Care Delivery in a Social Assistance Center in Mexico: A 14-Month Case Series of Children and Adolescents in Foster Care

1. Sandra H. Jee, MD, MPH 1. Department of Pediatrics University of Rochester Rochester, NY 1. Mark D. Simms, MD, MPH 1. Department of Pediatrics Medical College of Wisconsin Milwaukee, Wisc Improving the Odds for the Healthy Development of Young Children in Foster Care . Dicker S, Gordon E, Knitzer J. National Center for Children in Poverty: Columbia University Mailman School of Public Health. Promoting the Emotional Well-Being of Children and Families (Policy Paper No. 2). January 2002;1–28 Children and Family Services Reviews, Part V: Most States Fail to Meet the Mental Health Needs for Foster Children . Huber J, Grimm B. Youth Law News . 2004;Oct-Dec:1–36 CWLA Standards for Health Care Services for Children in Out-of-Home Care . Washington, DC: Child Welfare League of America; 1988. Educational Experiences of Children in Out-of-Home Care . Smithgall C, Gladden RM, Howard E, Goerge R, Courtney M. Chicago, Ill: Chapin Hall Center for Children at the University of Chicago; 2004:1–77 Fostering Health: Health Care for Children and Adolescents in Foster Care . 2nd ed. Task Force on Health Care for Children in Foster Care, American Academy of Pediatrics, District II, New York State. Elk Grove Village, Ill: American Academy of Pediatrics: 2005 Healthy Foster Care America . www.aap.org/advocacy/HFCA/ On any given day, more than 500,000 children are living in state-supported foster home care. In the course of a year, more than 800,000 children experience placement in a foster home. Many of these children return home quickly, but for some, placement may extend for years and may involve care in multiple foster homes. Most of the children have experienced serious family dysfunction prior to placement, including exposure to domestic violence and to their parents’ mental health disorders, addiction, or criminal activity. Serious neglect and abuse are the most frequently stated reasons for removing children from their parents’ care. Children entering foster homes have extremely high rates of physical and mental health problems, developmental delays, and educational underachievement. As a group, children in foster care …

Adolescents with chronic illness in the general population are at increased risk of mental health and behaviour problems. Depression is also associated with delinquency. Adolescents in foster care are more at risk for chronic illness and mental health issues. We investigated whether adolescents in long-term foster care with chronic illness have associated higher rates of internalizing and externalizing problems and delinquency. We also investigated if depression mediates the relationship between physical health and externalizing behaviours. Data are from the National Survey of Child and Adolescent Well-Being; adolescents age 11 and older residing in long-term foster care (n = 188). Children whose caregivers reported on the occurrence of a chronic illness were compared using anova on internalizing and externalizing subscale scores and total scores of the Youth Self Report (YSR) and Child Behavior Checklist (CBCL), and modified Self-Report of Delinquency (MSRD) scores of delinquency and total number of delinquent acts. Bootstrapping analyses were used to test our hypothesis that depressive symptoms (Children's Depression Inventory) function as a mediator. Adolescents with a chronic illness reported greater internalizing (YSR: F = 7.069, P = 0.009; CBCL: F = 4.660, P = 0.032) and externalizing (YSR: F = 5.878, P = 0.016; CBCL: F = 3.546, P = 0.061) problems, a greater number of delinquent acts (6.66, F = 5.049, P = 0.026) and heightened overall delinquency (F = 5.049, P = 0.026). Depression significantly mediated the effects of overall health on delinquency (95% CI, 0.03-1.76). It is important to consider the complex interrelationships between physical health, mental health, and behaviour for adolescents in foster care. These findings support the need for comprehensive services for these youths, including specialized assessments and collaboration between protective services and healthcare systems.

<p>Background: The Program of All-inclusive Care for the Elderly (PACE) is a program of care that enrolls nursing home eligible and offers them community-based long-term services and supports (LTSS). Many PACE enrollees are “dual eligibles” (DEs) meaning they qualify for Medicare and Medicaid services. Dental care is a unique feature of PACE among LTSS, as many LTSS do not include dental care, even though this population has difficulty in accessing these services. However, little is known about the delivery of dental care at PACE and how dental care and oral health promotion and prevention is being integrated into PACE. Thus, the purpose of this study is to describe the delivery and integration of dental care at PACE.</p> <p>Methods: Based on ten preliminary interviews and the PACE manual from the Centers for Medicare and Medicaid Services (CMS), a 56-question survey was developed to describe the delivery and integration of dental care at PACE across the country. In addition, the survey asked programs to rank their focus among five specialties (dentistry, mental health, optometry, audiology, podiatry), to determine if a program’s focus on dental care would influence the delivery and integration of dental services at PACE, and if this would lead the program to have a very high percentage of new and continuous enrollees with regular dental examinations. A publicly available contact list was obtained from CMS and the survey was distributed to all 124 PACE programs via email.</p> <p>Results: Respondents in this study represented 35 programs (28.2%) in 23 states (74.2%). Most programs had no limits for dental care, minimal waitlists, and provide most dental services without exclusions. This is evident by the 51.4% of programs that have no dental budget, 100% of programs providing preventive and basic restorative dental care, and nearly 100% offering advanced restorative services. Many programs also did not have a waitlist for non-emergent dental care. Few programs include a dentist in the routine operations of the PACE program, as evidenced by few programs having dentists conduct the dental assessment for the initial comprehensive assessment or having a dental director.</p> <p>A statistically significant association with a high percentage of reported utilization of dental examinations was detected with programs having a system for quality assurance for dental care (t=0.358, p=0.024), a protocol for a dental cleaning every 6-12 months (t=0.595, p<0.001), mandating a comprehensive dental examination (t=0.390, p=0.007), and providing preventive dental services onsite with built-in equipment (t=0.454, p=0.001). No factors were statistically associated with the focus ranking for dentistry among the other specialties.</p> <p>Conclusion: This study suggests that compared to nursing homes, PACE enrollees may have greater ability to receive dental care without limitations of the state adult Medicaid dental benefit. Dentistry also appears to be a high focus for some PACE programs. This study has begun to identify structures that support positive outcomes that can be used to develop best practices and guidelines for the delivery of dental care in PACE and other LTSS. Future studies are needed to better understand barriers and facilitators to the delivery of dental care and other specialty services.</p>

The relationship between extracurricular activities and delinquency of adolescents in foster care

Cluster analysis of maltreatment-related mental health symptoms manifested by adolescents in foster care suggest the absence of an underlying taxonomic structure. To test this further, we investigated alignment between mental health symptom profiles derived through cluster analysis and nominal diagnosis of Borderline Personality Disorder (BPD) and Complex Post-traumatic Stress Disorder (C-PTSD), among a sample of 230 adolescents in long-term foster care. Nominal DSM-V BPD and ICD-11 C-PTSD caseness was estimated from Child Behaviour Checklist and Assessment Checklist for Adolescents score algorithms, and alignment of case assignment with previously-derived symptom profiles was examined. Nineteen BPD and three C-PTSD nominal cases were identified. Low C-PTSD prevalence reflected low concordance between PTSD and ‘disturbances in self organization’ (DSO) case assignment. The BPD and C-PTSD cases were aligned to more complex and severe symptom profiles. While the complex and severe presentations identified in the present study included core symptoms and clinical signs of BPD, they were also characterised by clinical-level inattention/over-activity and conduct problems. The present findings provide some support for the validity of the BPD construct for describing complex and severe psychopathology manifested by adolescents in foster care, and no support for the C-PTSD construct. However, the symptom profiles point to high variability in combinations of multiple symptom types that does not conform to traditional definitions of a ‘diagnosable’ mental disorder. Further research is needed to determine if complex post-maltreatment symptomatology can be validly conceptualised as one or more complex disorders.

Niños y adolescentes en acogimiento transitorio: problemas de salud y directrices para su cuidado

The Brief Assessment Checklists (BAC-C, BAC-A): Mental health screening measures for school-aged children and adolescents in foster, kinship, residential and adoptive care

Black adolescents in the foster care system are at risk for a wide variety of negative outcomes. However, little is known about the role of multilevel promotive factors, particularly relational permanence, in promoting resilience in regards to race and gender for Black adolescents in foster care. This longitudinal study examines whether gender impacts the association between multilevel promotive factors and psychological well-being among Black adolescents in foster care. Participants were 489 Black adolescents who completed the Illinois Department of Children and Family Services Child and Adolescent Needs and Strengths assessment between 2007 and 2012. It was hypothesized that promotive factors would play a different role for Black boys and girls. Findings indicate that relational permanence was positively associated with psychological well-being for Black boys, but not for Black girls. Additionally, maltreatment type and number of placements also significantly predicted relational permanence at Time 2 for boys, but not girls. Taken together, these findings suggest that more attention needs to focus on promotive factors that predict positive outcomes for Black girls in the foster care system. Implications for practice and policy related to the gendered needs of Black adolescents in foster care are discussed.

To describe the dimensions of health and illness from the perspective of adolescents in foster care. Descriptive analyses of dimensions of health were conducted on N = 105 adolescents in foster care. Differences among demographic (age, gender, race/ethnicity) and foster care placement (age at first placement, reason(s) for foster care placement, length of time in care, number, and types of placement) variables and the dimensions and subdimensions of health (Child Health and Illness Profile- Adolescent Edition) were determined using T-tests and ANOVA. Most were placed in long-term foster care (x = 6.46 years; SD = 4.86) during adolescence (38%), with multiple placements (x = 3.99; SD = 3.8). All domains of health were self-reported to be average to low average, with poorer findings in specific risk and resilience subdomains. There were no significant differences by age or race/ethnicity. Girls had lower satisfaction with health and self esteem and more physical and emotional discomfort. Pre-placement adverse experiences were associated with increased risks. Adolescent self-report of the domains of health for those in foster care was better than expected, based on literature review and qualitative data for the larger study. Potential explanations for this inflation of status and functioning include the need for self-protection in foster care, the familiarity of testing regimes by children in foster care with some social desirability effect, and their paradoxical responses to pre-placement problems. Data including qualitative and significant other-reported data may be necessary to gain an accurate portrayal of the health status of adolescents in foster care.

African American children are disproportionately over-represented in the child welfare system. Many of these children linger in the system and experience disconnection from their biological families, communities, cultural beliefs, values, and practices. Familial socialization and cultural exposure are essential to developing a positive ethnic identity and self-concept. For African American female adolescents, hair and hair care are critical areas for such socialization and support. This qualitative study explored the hair and hair care perceptions and experiences of African American female adolescents in foster care. The goal was to examine hair and hair's connection to, and influence on, sense of self and self-esteem for African American female adolescents in foster care. Eleven African American female adolescents participated in individual interviews, and grounded theory was used to analyze the data. Four major themes emerged: hair care, perception of hair and identity as an African American female, societal influences on self-awareness, and influence of the foster care system. Results from the study indicated African American female adolescents in foster care identify hair as important. Participants noted hair is connected to appearance and shapes who they are and how they view themselves as African American females. Participants addressed the complexity of hair and politics associated with hair. The findings further emphasized the role of racial socialization and the importance of a supportive hair care environment. Participants also discussed their awareness of societal influences on their perception of African American women. They offered recommendations for improving the hair care experiences of African American children in foster care, for supporting positive development of identity and self-esteem, and for implementing standards of practice that will ensure these youths' cultural needs are addressed in the child welfare system.

The American Occupational Therapy Association's Centennial Vision advocates for an emphasis on intervention and prevention services for children, young people, the aging, and those with severe and persistent mental illness. This article discusses mental health issues among adolescents in foster care, a population that would greatly benefit from occupational therapy services emphasizing skill development in the areas of independent living, vocation, and health. Additionally, current intervention modalities used by other disciplines with adolescents in foster care are explored. Finally, a pilot study demonstrating the opportunities for occupational therapists to influence the long-term outcomes of adolescents in foster care is described.

Differential neural sensitivity to social inclusion and exclusion in adolescents in foster care

Adolescents in foster care are exposed to maltreatment and inadequate social support which can have lasting repercussions on their emotional development. The aim of this study was to examine the effect of social support on the use of emotional regulation strategies in Ecuadorian adolescents in foster care and non-foster peers. This study recruited 181 adolescents, 56 in foster care and 123 non-foster peers, from various locations in Quito, Ecuador. Participants completed the Cognitive Emotion Regulation Questionnaire (CERQ) and the Multidimensional Scale of Perceived Social Support (MSPSS). Using linear regression, we found that being in foster care was related to lower perceived social support. The non-foster care control group reported using more emotion regulation strategies, both adaptive and maladaptive (acceptance, rumination, refocusing to planning, and self-blaming), than the foster care group. Greater social support was associated with the use of more positive strategies (reappraisal, positive refocusing, and refocusing to planning) and less maladaptive strategies (catastrophizing). Youth in foster care have less social support than their non-foster peers. This puts them at risk, as social support has an important role in the use of healthy emotion regulation skills in adolescents.

Contact between children in foster and residential care and their birth families have an impact on children’s development and on placement stability. Contact is also important for their social relationships and sense of belonging and well-being. The aim of this study was, from children’s point of view, to describe, analyse and compare contact in residential care and foster care in terms of its frequency, visit location, feelings during and after the visits, visit difficulties, happiness with their placement, their self-confidence, future perception about their lives, and perception of their subjective well-being. We used a sample of 145 children in residential care and all the children in foster care (39), aged between 11 and 15, from the same four Portuguese districts. Results indicated that children in residential care had more contact and visits with their parents than children in foster care, being phone calls the most used way to contact the children. The majority of the children presented joy or satisfaction during parents’ visits and more diffuse feelings after the visit. Also, most of children would like to have more visits and just a minority present some difficulties in their fulfilment. Nevertheless, children in foster care had more self-confidence, optimism in relation to their future, happiness in relation to their placement and higher subjective well-being than children in residential care. In summary, it seemed that the type of placement for children at risk is more important to their future than the existence of contact with their parents.

More than 26,000 children and young people are placed in out-of-home care in Sweden every year. Several studies show that children placed in out of home care have poorer health during childhood and are generally in poorer physical condition later in life. The overall aim of this thesis was to study dental health and dental care in children in out-of-home care (OHC), through registry-based research. Paper I was a registry-based study of dental health care utilisation among young adults who as children had been placed in societal out-of-home care. These young adults had more emergency dental visits and more extractions and fewer regular scheduled dental check-ups than their peers who had never experienced OHC. Paper II was a systematic review/HTA to evaluate organisational models intended to ensure that children and young people in out-of-home care will receive health and dental care. We were unable to identify any study, of low or medium risk of bias, which examined the effects of organisational models on provision of health and dental care for children and young people in foster care and in institutions. Papers III and IV were validation studies of the Swedish Quality Registry for Caries and Periodontal Diseases (SKaPa), undertaken to determine the accuracy of the registry and whether it was appropriate for application in the next study (Paper V) and for other research purposes. For dft/DFT, the validation studies showed high agreement between the data in the patient records and the SKaPa registry. However, e/M in deft/DMFT was shown to be uncertain. Paper V was a registry-based study linking different registries, to investigate dental health and dental care in children in OHC. This study showed that children in OHC have more caries and undergo fewer dental health assessments than those who have never been placed in OHC. There was a difference in dental health examinations before and after the year 2017, with higher frequencies of assessments after the legislative amendment in 2017. However, differences remain.