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The physical and mental health of children in foster care.

Background To evaluate physical and mental health in children in foster care and comparison with general population. Methods: The study is carried out between September 2011 and April 2012 into nine group homes in Rome. It involved 112 children ranging in age 2–17 years, living in temporary care facilities or institutes. All data came out of clinical history and physical exams, validated by a pediatrician. Such data were being then compared with samples of general population. Results: Significant themes were high percentage of children with psychiatric disorders in foster care (22.3%); high percentage of psychiatric disorders diagnosed immediately while arriving at the foster care (56%); no significant differences in weight, height and BMI between children in foster care and general population; significant differences (P<0.05) for allergy, gastrointestinal diseases and caries between children in foster care and general population. Conclusion: The results suggest that the physical health of children in group homes is no worse than that of children living care in their own homes and that the foster care provides necessary conditions to support the growth of the children and their physical, mental and social needs.


Introduction
Foster care is a social system based on institutions, group homes or private homes for orphaned, abandoned and maltreated children. There are many epidemiological studies about this situation and all surveys show an increasing number of children in foster care (1). In the United States a recent report estimates that up to eight million children currently live in orphanages (2009 estimate by Save the Children UK) (2), and more than 400.000 children are in foster care (3). A 2010 Eurochild comprehensive survey reports approximately one million of children in the EU is living in alternative care, including residential, commu-nity and family-based care; Eurochild is a network of organizations and people working in and across Europe to promote children and youth's rights and improve their quality of life (4). In Italy 30900 children live outside their biological family, 15700 of this group live in residential home and other 15200 live with foster parents. These statistics come from a report of the Italian Ministry of Labor and Social Policy in 2009 (5). All national and international surveys show a real difficulty in understanding the extension of this growing reality. In Italy the child welfare system is managed by each region; the lack of a close network among regions and among all the residential host children homes, creates inhomogeneous situations with different outcomes in all the Country (6). Placement in foster care is now seen as a solution to the care problems of children whose parents are unable, unwilling, or judged by the legal system as unfit to care for them (7). The children for whom substitute parents are sought are likely to have complex physical, developmental, emotional and educational needs. Often they have been damaged by inadequate parenting, abuse and neglect (7). Studies about the health status of children in foster care detect that the health care needs are strongly dependent by the factors that determine foster placement (8). The placement is due to different reasons such as abandonment, poverty, neglect, physical or sexual abuse, drug use by biological parents, parental psychopathology and family breakdown; based on that, it is not surprising the high prevalence of mental health problems (9).The particular experience of each child affects greatly his or her health from a physical, mental and social point of view. In literature, the physical and psychosocial health of children in institutional care has been widely investigated for nearly 70 years. Children in foster care have mental health problems, anxiety, depressive symptoms or general mental difficulties (8)(9)(10)(11) and the overall health care of children who have been established in care for more than six months is significantly worse than for those living in their own homes (12). Children and adolescents which become part of child welfare system, whether through foster care, kinship care (placement with relatives) or residential institution care, are at a higher risk of suffering from a mental disorder; this condition has strong negative effects on everyday living and on QOL (11). Because of the significant prevalence of mental health disorders in the foster care population, many children welfare agencies have adopted the philosophy that addressing the well-being of these children requires multimodal service plans that need partnership and collaboration with mental health collaborates (13). Only few studies in Italy give a picture of the health needs of children who are established in foster care. An understanding of the health and mental problems of children and adolescents in foster care is a way to meet their needs and have a comprehensive care to this vulnerable population. Our study assesses the physical and mental health of children in foster care, in particular, of children in group-homes. Placement in group-homes is a bridge between the biological family and the adoption or the came back to the own family; our study aims to understand this kind of reality from a pediatric point of view. The study assesses the following elements: 1) weight, height and BMI of children in group home in comparison with a samples from general population to identify differences in the growth; 2) presence of diseases (allergies, flu, respiratory diseases, gastrointestinal diseases, urinary tract infections, dermatological diseases, obesity, caries and others) in children in group home and in the samples from general population; 3) children's mental status in group home.

Methods
Data for this study come from pediatric evaluation of a sample of children in group-homes in Rome. The data were collected between September 2011 and April 2012 with the permission of Guarantor of the Child and Adolescent and of Lazio's Regional Council; these are the main responsible institutions of group homes and foster care system in Italy. The latest records epidemiological analysis indicates that in Lazio Region there are 1.744 children in foster care and 233 group homes (6); nine of the most representative ones were chosen for the study. The evaluation included a complete history and physical examination by a pediatrician collecting the following information: age, gender, nationality, age of placement in group home, resident time in group home, reason for placement, ancient anamnesis, current anamnesis; growth parameters as weight, height and BMI. The information about current diseases was collected in the following diagnostic categories: allergy, respiratory diseases, flu, gastrointestinal diseases (celiac disease, ulcers, and colitis), obesity, dermatological diseases, urinary tract infection, caries and others (metabolic disorders, ocular disorders, and enuresis). About the ancient and current anamnesis, the study considered only certified diagnosis by a hospital or pediatrician. For minor's protection, the data and the growth parameters were collected in anonymous way and in the presence of the responsible of the family home. The study included 112 children ranging in age from 2 years to 17 years, living in temporary care facilities or institutes. Most of the children (85.7%) came from Italy, 6.3% came from East-Europe, 6.2% came from Africa and 1.8% from Asia. The community comparison group consisted of 112 children of general population whose data were collected from a family pediatrician in the Rome area. All the children of the comparison group were Italian. Data were analyzed using SPSS for Windows, version 18.0. Sample t-test was used to test the statistical significance of differences for weight, height in the two groups. Mann-Whitney U test was performed to test the significance of differences in BMI, which were not normally distributed. Pearson Chi square analysis was used to test the statistical significance of differences in the diagnosed concerning the two groups.

Results
The mean age of children in group-home was 10.5 years (SD +/-4.2); 33% were male and 67% were female. The mean age in comparison group was 10.6 years (SD +/-4.3%); 54% were male and 46% were female ( Table 1). The mean age of placement in group-home was 7.5 years (SD 3.8) and the average time of stay was 2.8 years.

Parameters of growth
Comparing weight, height and BMI every group was divided in male and female to decrease the data variability. There were no significant differences for weight, height and BMI between the study group and comparison group ( Table 2).

Health history
The ancient anamnesis detected at the time of placement in group-home showed 79.5% was healthy and 20.5% had a disease with certified diagnosis. This percentage of 20.5% included complications of perinatal disorders, congenital malformations and metabolic disorders (52.2%) and psychiatric disorders (47.8%). Different types of mental disorders were recorded: mood disorders, mental retardation, developmental delays including speech and language delays, depression, anxiety, post-traumatic stress disorders, and aggressive behavior. The current anamnesis found the percentage of children with psychiatric disorders in group-home was 22.3%. The most of these children received a correct diagnosis only after the arrival in grouphome (56%). Every child when arrives in group home was examined and followed by a psychologist to understand if their adverse experiences have damaged his mental status and if he needed to be followed by a psychiatrist to restore a balance in the growth. Data from other diseases, diagnosed in the study group, are reported in Table 3. The significant differences were for allergy, gastrointestinal diseases and caries (P<0.05).

Discussion
This study is a picture of the physical health and mental status of children in group-homes and it wants to show how the foster care is a valuable tool to attend children. The study chose to shed light on groups home because the most part of children in foster care spends its childhood in this structure. The age and the time spent in foster care underline a real difficulty to be adopted for the older children and this reflects the long time of the Italian authorities to handle these cases (6). All the children come from a particular reality and the health care needs are strongly shaped by the factors that necessitate foster placement (8). The 90% of children in foster care, placed by Juvenile Court, came from a neglect situation: the parents or other persons' failure with serious responsibility to provide needed food, clothing, shelter, medical care or supervision threaten the child's health, safety and well-being (14). Who cares of this particular vulnerable children has to consider the difficult past history before time of placement because it strongly influences health needs and, in particular, the care giver has to recover the parental mistakes. The most common reasons for a child's placement in foster care are neglect (44%), followed by abuse (13%)(13); child's neglect is for some mental function, as the language and its development, more detrimental than of child's abuse (13) and it is responsible of a part of the percentage of children mental disorders. There is a close network between the adverse life history (abandonment, neglect, abuse) and the psychopathology. Maltreated children placed in out-ofhome care are at high risk for exhibiting symptoms of psychopathology by virtue of their exposure to numerous risk factors (15). Child maltreatment is a high risk factor for psychopathology (15). The percentage of children with mental disorders was 9.8% before the arrival in group-home; immediately after, this percentage increased to 22.3%. We explain this increase thanks to the pediatric e psychiatric screening tested on each child when he arrives in group-home. Most of the study samples have received a diagnosis of a psychiatric disorder only when they have left the biological family to underline how their history influences their health status. All the children with a mental disorder constantly are followed by a psychiatrist and a psychologist during the time that they stay in group home and also when they will came back to their the biological family. A history of permanence in foster care is one risk factor for psychiatric disorder among homeless young adults (16,2): this relationship poses a strong recommendation for mental health screenings (13). The American Academy of Pediatrics (AAP) considers children in foster care to be a "discrete pediatric population with more intensive service needs than the general pediatric population or even other children who are poor" (17). The "picture" of the health status of children in grouphome underlines some similarities and differences from general population. From the assessment of weight, height and BMI we note how the growth is the same between two groups: to mean how the children's growth in group home is no worse than that one of children of general population. When a child arrives in group-home, he does not stop his growth and he can continue his route. Disorders as allergy and gastrointestinal diseases need specific test as Prick test and laboratories tests and a clinical observation over time by a pediatrician. These conditions are perfectly satisfied in the general population while for children in group-home is more difficult to obtain. Caries are most widespread among children in foster care to mean how hygiene habits and dental care are not controlled; this form is defined medical neglect as failing to provide any special medical treatment or mental health care needed by the child (14). The results about inadequate dental care are in tune with those reported in a case-control study of the health of those looked after by local authorities in UK. Children in foster care had more inadequate dental care than children living in their own homes (12). The literature identify potential barriers to use of dental care and oral health among children living in foster care: 1) linguistic and cultural barriers; 2) lack of dentists willing to accept children's Medicaid dental insurance; 3) lack of resources available to case workers (i.e., large caseload burden); 4) lack of federal funding for specialized dental care; 5) lack of systematic health record-keeping; 6) child transience, leading to the lack of a dental home; 7) foster parents' competing needs; 8) child behavior problems; 9) lack of dental "buy in" from adolescents (18).
In agreement with the literature, this study underlines the high percentage of mental disorders in children in foster care, but also it underlines how with the arrival in the group home the children have the opportunity to be evaluated by pediatric and psychiatric screening and followed overtime. All the children received into local authority accommodation are offered a "health assessment" by community pediatricians, and social services are automatically informed if they fail to attend (12). A potential limitation of this descriptive analysis is the lack of complete information about the health status of each child before the arrival in foster care. To solve this defect a national computer system should be incorporated where the health history of each child should be reported.

Conclusion
Although the physical health of children in group homes is no worse than that of children living in their own homes, there are still serious deficiencies in their overall health and well being, particularly in emotional health and behavior. Foster care provides necessary conditions to support the growth of the children and their physical, mental and social needs.

Ethical considerations
Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors.