Children who join families through the process of adoption, whether through a domestic or international route, often have multiple health care needs. Pediatricians and other health care personnel are in a unique position to guide families in achieving optimal health for the adopted children as families establish a medical home. Shortly after placement in an adoptive home, it is recommended that children have a timely comprehensive health evaluation to provide care for known medical needs and identify health issues that are unknown. It is important to begin this evaluation with a review of all available medical records and pertinent verbal history. A complete physical examination then follows. The evaluation should also include diagnostic testing based on findings from the history and physical examination as well as the risks presented by the child's previous living conditions. Age-appropriate screenings may include, but are not limited to, newborn screening panels and hearing, vision, dental, and formal behavioral and/or developmental screenings. The comprehensive assessment may occur at the time of the initial visit to the physician after adoptive placement or can take place over several visits. Adopted children can be referred to other medical specialists as deemed appropriate. The Council on Adoption, Foster Care, and Kinship Care is a resource within the American Academy of Pediatrics for physicians providing care for children who are being adopted. Pediatricians have played a significant role in the adoption process, in some cases providing counseling to parents during the preadoption phase and subsequently providing health care for these children. Special needs among adopted children need to be identified so they may be evaluated and treated appropriately. The pediatrician also needs to become knowledgeable about the resources available to help families integrate the new adoptee into the family unit. The purpose of this Clinical Report is to provide the general pediatrician with practical guidance that addresses the initial comprehensive health evaluation of adopted children.
Pediatricians regularly care for children who have experienced child maltreatment. Child maltreatment is a risk factor for a broad range of mental health problems. Issues specific to child maltreatment make addressing emotional and behavioral challenges among maltreated children difficult. This clinical report focuses on 2 key issues necessary for the care of maltreated children and adolescents in pediatric settings: trauma-informed assessments and the role of pharmacotherapy in maltreated children and adolescents. Specific to assessment, current or past involvement of the child in the child welfare system can hinder obtaining necessary information or access to appropriate treatments. Furthermore, trauma-informed assessments can help identify the need for specific interventions. Finally, it is important to take both child welfare system and trauma-informed assessment approaches into account when considering the use of psychotropic agents because there are critical diagnostic and systemic issues that affect the prescribing and discontinuing of psychiatric medications among children with a history of child maltreatment.
The child welfare system strives to provide children and adolescents in foster care with a safe, nurturing environment through kinship and nonkinship foster care placement with the goal of either reunification with birth parents or adoption. Pediatricians can support families who care for children and adolescents who are fostered and adopted while attending to children' s medical needs and helping each child attain their developmental potential. Although this report primarily focuses on children in the US child welfare system, private and internationally adopted children often have similar needs. THE FACES OF CHILD WELFARE IN THE UNITED STATES The child welfare system strives to protect the safety of children while supporting families whose children are placed in foster care. In this document, the term "child" includes infants, children, adolescents, and young adults. The child welfare system also serves as a bridge to the primary goal of permanency through reunification or adoption. On September 30, 2018, the Adoption and Foster Care Analysis and Reporting System reported that 437 283 children and adolescents were in foster care. 1 Of these children, 262 956 entered foster care during the fiscal year of 2018, with 250 103 exiting foster care. The number of children served in the foster care system during 2018 was 687 345. There were 125 422 children waiting to be adopted, with 71 254 having parental rights terminated and 63 123 subsequently being adopted from care. Primary reasons for entering foster care include neglect (62%), parental substance use (36%), poor coping skills of the caregiver (14%), physical abuse (13%), and inadequate housing (10%). Other reasons that account for less than 10% in each category include child behavior problems, parental incarceration, parental alcoholism, abandonment, sexual abuse, child disability, relinquishment, parental death, and child alcohol and other substance use. 1 A growing number of children, estimated to be 5% to 10%
At an estimated prevalence of up to five percent in the general population, fetal alcohol spectrum disorders (FASD) are the most common neurodevelopmental disorder, at least if not more prevalent than autism (2.3%). Despite this prevalence in the general population, pediatricians and other developmental specialists have thus far failed to diagnose this disability, leaving most children and adults without the supports provided for most other disabilities. This paper will provide a review of clinically relevant literature that describes the developmental challenges of children with fetal alcohol spectrum disorders and addresses similarities to and differences of FASD from other neurodevelopmental disorders such as autism and attention deficit hyperactivity disorder. A subsequent discussion will describe how a diagnosis of an FASD can establish a basis for understanding the developmental and behavioral challenges of children with an FASD, and how specific interventions can help support child development and maximize adult independence.
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