A Presentation to the 2015 Legislative Session Children’s Caucus Monday, January 12, 2015

1. Colorado's Efforts to Address the Behavioral Health Needs of Children Who Live in State Care:Addressing the use of psychotropic medications and ensuring proper mental health treatment for children A Presentation to the 2015 Legislative Session Children’s Caucus Monday, January 12, 2015 Kathryn Wells, MD, FAAP

2. Top 10 Things Every Legislator Should Know about Children in Out of Home Placement Perspective from a Pediatrician Based on “10 Things Every Pediatrician Should Know About Children in Foster Care” by Moira Szilagyi, MD, PhD, FAAP • https://www.AAP.org / Foster Care

3. “Top Ten List”#10 - Removal is Traumatic • Parents • Community / Schools • Siblings

4. #9 - The Things They Carry • What is in the bag is within? • Temperament, experiences, coping skills, strengths • Young-childhood trauma • Don’t carry – Health histories, Medications, etc.

5. #8 – The Impact of Childhood Trauma • Children live what they learn • Behaviors • Attachment issues • Impulsive/Hyperactive/ ADHD • Poor attention • 80% of brain development occurs before age 5

6. Adverse Childhood Experiences More than 17,000 Kaiser members More than 50 scientific articles Study found that ACE are common Almost two-thirds of study participants reported at least one ACE, and more than one of five reported three or more ACE The short- and long-term outcomes of these childhood exposures include a multitude of health psychological and social problems

7. Adverse Childhood Experiences ACEs • Of 17,000 Participants: • Sexual Abuse • Physical Abuse • Emotional Abuse • Emotional Neglect • Physical Neglect • Household Substance Abuse • Parental Divorce • Household Mental Illness • Mother Treated Violently • Incarcerated Household Member • 36% 0 ACEs • 26% one ACE • 16% 2 ACEs • 9.5% 3 ACEs • 12.4% 4+ ACEs

8. Adverse Childhood ExperiencesOutcomes Alcoholism and alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Fetal death Health-related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease • Risk for intimate partner violence • Multiple sexual partners • Sexually transmitted diseases (STDs) • Smoking • Suicide attempts • Unintended pregnancies • Early initiation of smoking • Early initiation of sexual activity • Adolescent pregnancy

10. #7 – Children in Foster/Kinship Care are Children with Special Health Care Needs • Complex – Why? • Neglect • Trauma – physical • Parent unable to be a caregiver • Emotions / stress – exacerbate symptoms / illness • Disposable or “Transient” • 2/3 of children in foster care experience 3 or more placements per year • In Placement Δ Schools • Healthcare Provider Δ Therapist

11. #6 – Barriers to Improving Health Outcomes • Complex system to navigate • Obtaining consents and health information • Coordinating care • Confidentiality – teens • Collaboration • Referrals • Help with navigation • Navigating – child welfare system

12. Needs of Children in Foster Care Complex mix of unmet physical, developmental and mental health needs Complications of abuse and/or neglect, common childhood illnesses, mental illness, growth failure, developmental delays, sexually transmitted illnesses, high risk behaviors and chronic illness Preventative care

13. Children’s Medical Histories Often incomplete Often unavailable

14. Other Problems Children who are adopted often lack documentation of thorough medical family history Many doctors and dentists won’t see a child who doesn’t yet have a Medicaid card (this takes some days from the time a child enters care) Foster parents often have to pay themselves for necessary medications until the Medicaid card arrives

15. Other Challenges Most healthcare providers lack extensive training in recognizing the signs of abuse and neglect Social Case Work staff who generally are not trained extensively in medical and dental issues are each in charge of developing a child’s medical/dental history

16. AAP Guidelines • American Academy of Pediatrics – “Task Force on Foster Care” 2005 • Higher rate of health, developmental & behavioral problems • Require a specialized approach to medical care • Schedule of well child care specific to foster children • Model of care for foster care • Children need to be seen within 72 hours of placement • Track medical records • Within 30 days, need to establish medical home

17. #5 – Shared Goals • Temporary – safe situation • Health, safety (physical & emotional) • Reunification or adoption = permanency

18. #4 – The Foster/Kin Parent • Foster/kin parents are the heart & soul of the foster system • Can be under-prepared • May lack proper training • They are the advocate & voice • What about their loss?

19. #3 - Visitation • Best predictor of reunification • Can heal the relationship • May relieve trauma • Promises • Transitional object • Behaviors before & after visit

20. #2 – Medical Home • All children in foster/kin care deserve a home, but they also need a medical home • Consistent, comprehensive, family centered, compassionate, and coordinated • Stability & continuity of care and information • Should be your link to social services, specialty providers, and the community

21. #1 – The Power of the Medical System • Health / medical home - Liaison • Education - Tracking/data coordination • Advocacy - Holistic approach to foster care • “He was the nicest man in the world, and he was there almost every time I went. He had a way of taking children seriously which most adults can’t do. And he was even kinder to foster children than most pediatricians are to children with parents. He listened carefully and respectfully to everything I told him. He even seemed to believe me when I said I’d become a doctor someday. I was convinced he took me more seriously than I took myself.” • Francis Cournos, MD • City of One: A Memoir

22. Medicaid (HCPF) Healthcare Services • Child Welfare • Law Enforcement • Child Advocacy Center • Schools • District Attorney • Courts • Community Support Agencies

23. Medicaid (HCPF) Healthcare Services • Health Information Systems • Child Welfare • Law Enforcement • Mental Health Services • Child Advocacy Center • Schools • BHO • Primary Care Providers • Dental • District Attorney • Courts • RCCO • Developmental Specialists • Community Support Agencies

24. Denver HS (Medical Passport) • Family Crisis Center (FCC) • Connections For Kids Clinic (CFKC)