Meeting the medical and mental health needs of kids in foster care

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. A health care program for children in foster care marked 30 years of service in 2021, and today I'm speaking to its director. Dr. Steven Blatt is a professor of pediatrics at Upstate, where he also directs the ENHANCE health care services for children in foster care. Thank you for taking time to talk with me again, Dr. Blatt. It's my pleasure to be with you. Amber.

ENHANCE health care services for children in foster care has been operating for 30 years. Can you tell us how it came to be?

Steven Blatt, MD: Sure. So as with many communities back in the late 1980s, Onondaga County was going through a crisis in foster care, and the children's division for the county was developed at that time. And the deputy commissioner, a woman named Diane Erné, contacted Dr. Howard Weinberger, who was in charge of general pediatrics, and said, "How could we at Upstate help the county? So we met and planned and the county did the same, and we came up with the model, back in 1991, that is still pretty much the same today.

And it was based on what was then the best practices, the best available models that we knew of. And it's held up over the last 30 years.

Host Amber Smith: Why was there a crisis in the early '90s?

Steven Blatt, MD: So in the late '80s, early '90s, there are a number of things that had happened. One is HIV was reaching its peak, and, so many young mothers had to deal with thathorrific disease at the time.

It was also the peak of the drug epidemic, with cocaine especially. So we had a lot of people suffering from substance abuse as well as HIV. And the number of children in foster care were just exploding. And when we started in the early '90s, we had a thousand children in this county in foster care.

And so we had a lot of kids. We had a lot of parents who were not well equipped to handle the kids or to take care of themselves. And there was no organized system in place. One of the things that we've learned, especially during COVID, is that an organized medical system is much better than a disorganized one.

So back then there was no system in place to take care of the children. So the first thing that we did is, we established the system. We had one place, which was ENHANCE, at Upstate, back here for all the kids in the county in foster care. And we also had the proper staffing for it. Back then, as we do today, we have pediatricians, nurse practitioners, a child psychiatrist and a case worker from the county to provide care to this very complex population of children.

Host Amber Smith: What does ENHANCE stand for?

ENHANCE is an acronym that was created by one of our colleagues, Maureen O'Hara, when we started ,and it stands for Excellence in Health Care for Abused and Neglected Children. And I just want to focus on the first word, excellence, because that's been our guiding philosophy: to make sure that these kids get the excellent health care that they deserve. So I've seen it described that youprovide primary health care and comprehensive health care. What's the difference?

That's a great aspect you picked up on.

Steven Blatt, MD: So, primary care: People today, although not so much 30 years ago, but people today are familiar with the term PCP or primary care physician or primary care practitioner. And that means somebody to do the routine health care of children. So for children, it's a lot of immunizations, looking at child development, looking at the structure of the home, how they do in school, but comprehensive care acknowledges the situation these kids are in.

When you look at children entering foster care, they have a tremendous amount of mental health needs, developmental delays, unmet health care issues, such as asthma, children that have a high rate of being exposed to drugs and alcohol intrauterine. So we need extra services to provide for these kids.

And then on top of it, once they're in care, we're very active. Placing them into care creates new issues. You know, most kids do not have a judge who's going to oversee their care. Most children live with their family, and you don't have to make visits to visit with your family, and all of these types of issues and more create new opportunities for anxiety, depression and turmoil in a child's life.

So we need a lot of help to take care of these children.

Host Amber Smith: You said when this started, there were a thousand kids in foster care. What is that like now? How does that compare to today? And can you talk a little bit about how things have changed in 30 years?

Steven Blatt, MD: Sure. One of the biggest changes locally and nationally for kids in foster care was the 1997 Adoption and Safe Families Act, which is called the ASFA, A-S-F-A.

And what that did from the federal governmentis, it refocusedwhat we do in foster care to pay attention to a lot more of the child's needs. So one of the big ways that this is implemented is that when a child comes into foster care, the clock starts ticking. And within 15 months of placement into foster care, the county and the court system have to move towards either reunification with the biologic family, so send the child back to the mother or father, or to move forward with what's known as a TPR: Termination of Parental Rights. And what that means is the judge will decide that this child will never go home to the biologic family and will be free for adoption. So prior to ASFA, kids could stay in foster care for five years, for seven years, for nine years, for a very long time. Now with ASFA, the decision is made much sooner in the child's life to decide to reunify with the parents or to say they're going to be free for adoption. And partly because of ASFA, the population of children has decreased significantly. So now in this county we have between 450 and 500 kids in foster care, as opposed to a thousand 30 years ago. It was even lower than that, but it goes up and down depending upon what's going on. I think the other thing that has happened to help keep kids out of foster care, Is, I think there are a lot more services available to biologic parents to help them get back on track, because it's important to remember that for the vast majority of kids who go into foster care, their parents are not bad people.

They are people that have big-time problems. They suffer from alcoholism or mental illness or drug abuse, which is an illness. And they need help. The vast majority of them are people in poverty, and they lack skills, and they need help. So the goal is to help the parents become better parents, to become more independent, better citizens, so they could take their kids back.

And so there are more services to help these parents, who, I just want to emphasize again, are, by and large, nice people. There's some people who are not good parents, but most of them were just people with a lot of problems. And so there are a lot more services for these folks.

Host Amber Smith: You're listening to "The Informed Patient" podcast from Upstate Medical University in Syracuse, New York. I'm your host, Amber Smith. I'm talking with Dr. Steven Blatt, professor of pediatrics and the director of the ENHANCE health care services for children in foster care. From a pediatrician's point of view, how is a kid in foster care different from a kid who is not?

Steven Blatt, MD: So I spend time clinically taking care of kids in foster care and kids who are not in foster care.

And there's a lot of similarities and there's a lot of significant differences. To begin with kids in foster care need everything that every kid needs. They need a stable home and nurturing parents, loving parents. They need developmentally appropriate environments and good schools. If they're sick, they need their medications.

Kids in foster care need all of that, but there are a few things where kids in foster care are anticipated to have extra needs. So many of the kids coming into foster care have not been getting routine health care, so they could come into care either lacking appropriate immunizations or lacking health care.

So that they may have untreated asthma. They may have a lot of dental caries, but have never made it to the dentist. They may not have their eyeglasses. Kids in foster care, by definition, come from the neglected homes. So that increases their risk, that they will have different mental health issues. So many kids come into foster care, either needing counseling, or what they all need is a stable home and a stable foster home could really help stabilize many of these children and the different,things they're going through, such as anxiety, depression, conduct disorder. So they need stability and everybody needs that, but kids in foster care, by definition, all need it.

And that's why they need access to a lot of professionals. So we provide them with a lot more doctor-patient time. We have a child psychologist. Many, many of them end up in counseling or come in with counseling and continue that. And then the foster parents, they need a lot of support too, because these are kids who, even if you take a child and put them into a nicer home and a more stable home, with more resources, it's still not their home. And that is very anxiety provoking to anybody. A child an adult, an adolescent, anybody out of their home, they get homesick in one way or the other. They miss their home, the smells, the food they eat, their friends. They move to a different neighborhood, maybe different schools. And so it's very anxiety provoking. It's upsetting, it's depressing. And so the foster parents have to take care of these kids day by day and support them. And then, the kids have to learn a new way of living, and the foster parents have to guide them through this.

Steven Blatt, MD: So the foster parents need a lot of support also.

Host Amber Smith: Do you see, among foster kids, do you see a higher proportion of chronic medical conditions? In addition to some of the mental health things you described?

Steven Blatt, MD: Absolutely. When you look at kids in foster care, some of them, when they come into care, the neglect that they have has created medical conditions, such as poor growth is one, certainly mental health issues.

There are some kids, unfortunately that come in, they've been physically abused or sexually abused. And all of these things have physical and mentalproblems that persist. And then other things: I mentioned asthma before; we have great medications, great tools to treat asthma, but if you don't have access to them, you're going to be in bad shape. And many of the kids that come from environments, where, because these kids are in poverty, they may have environmental factors, such as mold and mildew and smoke that just make their asthma worse. So a lot of kids come into care with a history of chronic illness and recurrent illness, and once in care, a lot of these get remarkably better. Another thing that kids come in with are developmental delays. Some of it has to do with being in a neglected environment. Some of it has to do with just the genetics that they had; they were born with problems. But those kids need extra services, and if you're a parent that's struggling to begin with, you're not going to be able to get those extra services.

Host Amber Smith: How has the pandemic impacted kids in foster care and the foster care system in general?

That's a great question. And it's an important question. To begin with, the kids in foster care, like everybody else, nobody has come out of this pandemic without having issues without having bad things happen.For kids in foster care it's even worse. So let me share some of the things with you. So in the height of the pandemic, children were not allowed to visit with their biologic parents because everybody was on lockdown. So not only were you in foster care, but you couldn't see your parents, and yes, a lot of kids would do Zoom meetings, but if you're 6 months old, 15 months old, that doesn't work very well.

Steven Blatt, MD: Similarly, if you're a parent and you're told, OK, what you need is to go to, drug rehabilitation and the rehab center was closed down because the COVID, you can't begin your therapy. Soyou're in lockdown like everybody else, you don't have access to your kids, you don't have access to therapy, you're going to continue doing drugs. So it was not good for the biologic parents, then for kids and their parents in foster care, the judge would say, come back in six months, so we can check the progress on your case. But six months later, the courts are closed down. So you can't meet with your judge. So you're stuck in limbo even longer. And whether the judge wants to reunify the child with the parents or terminate parental rights, nothing happens. So there's a huge backlog in the courts.

So everything is just magnified for the kids in foster care, and then even things such as um, some of the health care things, and the biggest one is for COVID vaccine. Because when COVID vaccine first appeared for each age group, including the adolescents, and then the kids, it came out under emergency use authorization and we needed informed consent and the state and the county want the biologic parents to do that, so kids (in foster care) didn't have the same access to COVID vaccine as other kids.

Host Amber Smith: I had not realized that.

Steven Blatt, MD: Yeah, it's just one more barrier to getting COVID vaccine into kids. And we're getting some in, but it's very cumbersome.

Host Amber Smith: As the vaccines are becoming more widely available and more people are getting vaccinated, at least in the U.S., how soon do you predict that things will get back to normal in the foster care system? Because you mentioned there's quite a backlog.

Things are beginning to move again. Right now it's in December when we're talking, and last month was National Adoption Month, and, there were a number of adoptions, that happened in the county, which is nice because those children and families had been in limbo and the courts are operating again fairly regularly, although there are still some delays. So it's like everything else; it's coming slowly back online.

Host Amber Smith: Thank you for taking time to tell us about this. My guest has been Dr. Steven Blatt from ENHANCE health care services for children in foster care, and he's also a professor of pediatrics at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York.

I'm your host, Amber Smith, thanking you for listening.