From The Field D E C E M B E R 1 6 , 2 0 1 3 A Lawyer’s Role: Ensuring the Health of Children and Youth in Foster Care EVA J. KLAIN, J.D. Director, Child and Adolescent Health, American Bar Association Center on Children and the Law T oo often, legal professionals only come into contact from their abuse or neglect. Nearly 90 percent of children enter- with children and youth when they are involved in ing foster care have physical health problems, while over 50 some type of court action—whether before a judge in percent have two or more chronic conditions (Leslie et al. 2005). dependency cases, for delinquency or status offenses, or in One-third has dental and oral health problems (AAP 2013). domestic relations proceedings (such as custody, visitation, Many have high behavioral health needs, often leading to inap- child support, and domestic violence). Judges and lawyers are propriate or excessive use of psychotropic medications. Addressing trained to identify legal, rather than medical, issues. They need children’s health needs is an integral part of well-being, and to focus, however, on the health and well-being of their clients comprehensive and coordinated health care is critical to well- when safety considerations require that a child be removed being and positive long-term outcomes for children in care. from his or her home and placed in foster care. To promote healthy outcomes for court-involved children Many children and youth enter foster care with complex health and youth, the American Bar Association Center on Children care needs—many have acute illnesses or compromised systems and the Law works with other disciplines to distill and dissem- LAWS PROMOTING HEALTH AND WELL-BEING Attorneys can find support in several federal laws and consultation with health care and child welfare experts. programs for their efforts to address the health needs of their Each state’s plan must include a coordinated strategy to child and adolescent clients: identify and respond to children’s health care needs, • The Adoption and Safe Families Act made states including mental and dental health. accountable for providing services to address the safety, permanency, and well-being of children and families. • The Child and Family Services Improvement and For the first time, states were required to ensure that: Innovation Act requires states to account for the oversight and coordination of health care services for any child in • families have enhanced capacity to provide for their foster care, including monitoring and treatment of emo- children’s needs, tional trauma associated with a child’s maltreatment and • children receive appropriate services to meet their removal from home, as well as protocols for the appropri- educational needs, and ate use and monitoring of psychotropic medications. • children receive adequate services to meet their physical and mental health needs. • The Patient Protection and Affordable Care Act includes provisions that specifically apply to children and youth in • The Fostering Connections to Success and Increasing foster care or at risk of entering care. Most significant is the Adoptions Act addresses many issues that promote per- expansion of Medicaid coverage for youth who age out of manency and affect the health and well-being of children foster care—states are now required to make “former foster and youth in foster care, including: care children” eligible for Medicaid until they turn 26, pro- • increasing resources that help birth families stay vided that they turned 18 while in care or aged out of care together or reunite; and were receiving Medicaid at the time they exited care. • helping students stay in the same school or promptly In addition, child welfare agencies must now include sev- transfer when they enter care; eral health-related issues in transition plans for youth • making it easier for relatives to care for children; and aging out of foster care, including information about health • requiring states to develop plans to coordinate and insurance options and the importance of designating a oversee health services for children in foster care, in health care power of attorney or health care proxy. inate the health information legal professionals need to know. the health needs of both mother and child are addressed. Many opportunities exist for lawyers who serve children and • Children with Disabilities: Children with disabilities have their families to maintain a multidisciplinary approach to special needs that must be addressed during their child policy and practice issues related to health and well-being. welfare cases, and attorneys can use advocacy strategies that Through their advocacy efforts, attorneys can significantly protect them and enhance their participation in court. influence the achievement of positive well-being outcomes for court-involved youth, as well as reductions in disparities and • Trauma-Informed Legal Advocacy: Children in care are barriers that limit their access to quality, comprehensive more likely to have been exposed to multiple forms of trau- health care such as mental health and dental care. matic experiences and may be subject to further stresses upon entering the system. Multiple encounters with trauma HOW LAWYERS CAN MAKE A DIFFERENCE and stress can have significant consequences for the physical, emotional, and social well-being of children in care. While federal and state laws govern how child welfare cases are Attorneys can ensure their interactions with clients are handled within each state, attorneys can focus their attention trauma-informed and advocate for use of trauma-focused on each individual child client and his or her health needs. screening, functional assessments, and evidence-based Each case is unique, but certain general policy and practice practices to support the child’s resiliency and well-being. approaches can improve child health and well-being outcomes. • Medical-Legal Partnerships: Lawyers and doctors can work • Medical Homes for Children in Foster Care: Continuity together to address families’ legal and medical problems. of care through a medical home promotes better outcomes Medical-Legal Partnerships (MLPs) help families address for children, and attorneys can advocate for its many issues such as landlord-tenant problems or loss of public benefits, including increased immunization rates, fewer benefits that may have a direct impact on a child’s health, emergency department visits, decreased hospitalization, such as mold removal from an apartment to prevent recurrent and improved perceptions of quality of care. Foster care asthma flares. By ensuring that a family’s basic needs are met, medical homes can maintain a detailed health record for a MLPs increase children’s chances for positive health outcomes child who may move among placements or even in and out and may prevent the need for foster care placement. of the system, develop care plans for children with special health care needs, assume responsibility for care coordina- CONCLUSION tion, and exchange health information with child welfare agencies at regular intervals. It is only through knowledge of available resources and part- nership with other disciplines that legal professionals can fully • Quality, Evidence-Based Interventions and Services: understand the health-related issues they need to address on Attorneys can ask critical questions about service effective- behalf of their child clients. With increased in-court attention ness, both for the child and his or her parents. Based on to the health needs of children and youth in foster care, well- validated screenings and assessments, attorneys can advo- being outcomes for such children can significantly improve. cate for appropriate services to meet the child’s specific health needs. Likewise, if parents are not receiving appro- priate, quality services that address the circumstances that For more information, e-mail Eva Klain at Eva.Klain@ brought the child into the system, then the agency is not americanbar.org. fulfilling its responsibility to make reasonable efforts to achieve the permanency goal, especially when that goal is to reunify the family. SOURCES • Psychotropic Medication: Multiple studies have found American Academy of Pediatrics (AAP), “Dental and Oral children in foster care to be vulnerable to excessive or Health,” <http://www.aap.org/fostercare/dental_health.html>, inappropriate use of psychotropic medication. When accessed November 2013. advocating for the best interests of their child clients, attorneys should ask important questions to ensure that Courtney, M., A. Dworsky, A. Brown, C. Cary, et al., Midwest any medication is appropriately prescribed. These include Evaluation of the Adult Functioning of Former Foster Youth: whether other evidence-based therapies have been tried, who Outcomes at Age 26 (Chicago, IL: Chapin Hall at the University is monitoring the medication, what side effects are possible, of Chicago, 2011). and whether the child agrees with taking this medication. Leslie, L.K., J.N. Gordon, L. Meneken, K. Premji, et al., • Pregnant and Parenting Teens: Teen girls in foster care “The Physical, Developmental, and Mental Health Needs of become pregnant at a higher rate than teens in the general Young Children in Child Welfare by Initial Placement Type,” population. One-third of girls in foster care are pregnant Journal of Developmental & Behavioral Pediatrics 26(9) i3:177, by age 17 or 18, compared to just 14 percent of their gen- June 2005. eral population peers (Courtney et al. 2011). In some cases, a teen’s pregnancy may cause placement changes or disrup- tions that negatively affect both the teen mother and her Views from the Field is offered by GIH as a forum child. Advocates for such young mothers need to ensure for health grantmakers to share insights and experiences. If you are interested in participating, please contact Osula Rushing at 202.452.8331 or orushing@gih.org.