Deyanira Sanchez, DDS


To evaluate the knowledge and attitudes of California Pediatric Dentist towards treatment of the foster care population.

The American Academy of Pediatric Dentistry (AAPD) recognizes that providing both primary and comprehensive preventive and therapeutic oral health care to individuals with special health care needs (SHCN) is an integral part of the specialty of pediatric dentistry, yet there are no specific guidelines or policy recommendations for the care of foster children.
American Academy of Pediatric Dentistry. Reference Manual Overview: Definition and scope of pediatric dentistry. Pediatr Dent 2008;30(suppl):1.

Recent literature states that lack of knowledge of primary care providers is considered a barrier to access to care.

Currently there are no studies related to pediatric dentists’ knowledge and attitudes towards treatment of the foster care population.

The questionnaire consisted of 3 parts;  background information  attitudes  general knowledge.

Questions were a forced-choice format with response options varying depending on question content (e.g., yes/no, Likert scales) and distributed to Pediatric Dentist of the state of California.

Gender  Age  Type of practitioner  Place of practice Provider for Medical/Medicaid

What is the percentage of foster care children within the patient population at your primary place of practice? Do you know or document the reason for court appointment into care of the foster children in your practice?

Pediatric dentist General dentist Expanded Functions Dental Assistants Do they have the necessary training to provide appropriate care for the special health care needs of foster children?

The AAPD has established clear guidelines for the treatment and management of the health care needs of foster children.

Barriers to providing care to foster children
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Medical information is difficult to access Complex care is poorly coordinated. Reimbursement for medical services is low. Legal consent issues. Providers are uneducated regarding the specific health care needs of foster children. Health care delivery is disrupted by changes in child placement.

What is the current rate of entry of children in to the FC system in Ca? What is the most highly represented racial/ethnic group in FC in Ca? What is the most highly represented age group in FC in Ca?

What is the highest maltreatment type of child victims upon entry to foster care? What is the highest unmet need of children while in foster care? What is the ratio of children in foster care who have mental health needs?

What % of children in Ca. received a timely dental exam (less than 30 days) after placement in FC?

During the first two year of placement in FC, what % of children had 2 or more placement settings?

How many times more likely to give birth before the age of 21 are females in FC compared to general population.

Please select the highest reported health risk behavior between the ages of 12-14.

A minor who is 15 years of age or older, is living separate from parent/guardians, and is managing own financial affairs, may consent for dental care. A licensed care giver providing residential foster care may give consent for: o ordinary dental care. o surgical dental treatment.

508,000 children live in out of home care. 6.8 for every 1,000 children.

The placement is intended as a temporary arrangement, while birth parents receive services that will lead to reunification.

U.S. Department of Health and Human Services: Foster Care FY2002 – FY2006 Entries, Exits and Numbers of Children in Care on the Last Day of Each Fiscal Year.

The average length of stay is more than two years — 26.7 months. 11% of children in foster care have languished there for five or more years.

The AFCARS Report Preliminary FY 2009 Estimates as of July 2010: Adoption and Foster Care Analysis and Reporting System (AFCARS) FY 2009 data (October 1, 2008 through September 30, 2009). U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau,

Top 5 Juridictions
1. 2. 3. 4. 5.

California (78,373) Texas (30, 848) New York (29,973) Florida (29,229) Pennsylvania (21,135)

Administration of Children and Families, U.S. department of Health and Human Services



Multiple social stressors. Emotional disturbances.



Mentally retarded (<10%).
Addiction to drugs or alcohol. 1/3 abused or neglected themselves.
Moira Szilagyi; The Pediatrician and the Child in Foster Care: Pediatrics in Review 1998;19;39 pg.40




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27%-Juvenile Justice system. 3%-Voluntary Placement. Nationally, 4.1% of children are parentless.
Moira Szilagyi; The Pediatrician and the Child in Foster Care: Pediatrics in Review 1998;19;39 pg.40 U.S. Census Bureau. Living Arrangements of Children. (2001)

California Emotional Abuse Medical Neglect Neglect

2010 16.5 % 78.5 %

Physical abuse
Sexual Abuse Other Number

10.2 %
6.1 % 0.1% 82,879 (70% of total)

National Child Abuse And Neglect Data System


7,000 youth- Male/female ratio of 4:1 >50% are placed in high-level homes outside of their county or state. Very few prevention services are available for these children due to state cutback.
Child Welfare Services/Case management system (2008)

Gender is represented equally.

Preponderance of African-American mixed racial heritage.


The population of children <5 has increased by 110% from 1986-1991.
AMERICAN ACADEMY OF PEDIATRICS Committee on Early Childhood, Adoption, and Dependent Care PEDIATRICS Vol. 109 No. 3 March 2002

< 5 year old comprise 1/3 of population. Adolescents comprise 40%.

U.S. Department of Health and Human Services

Permanency Well Being Emancipating youth

Amy D'andrade PhD, Kathy Lemon Osterling PhD & Michael J. Austin PhD (2008): Understanding and Measuring Child Welfare Outcomes, Journal of Evidence-Based Social Work, 5:1-2, 135-156

More children are entering foster care in the early years of life when brain growth and development are most active.

It is known that emotional and cognitive disruptions in the early lives of children have the potential to impair brain development.

AMERICAN ACADEMY OF PEDIATRICS Committee on Early Childhood, Adoption and Dependent CarePEDIATRICS Vol. 106 No. 5 November 2000

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Poor attachment formation Poor physical development Understimulation Development delay Antisocial behavior

AMERICAN ACADEMY OF PEDIATRICS Committee on Early Childhood, Adoption and Dependent CarePEDIATRICS Vol. 106 No. 5 November 2000

86.7% had a physical health problem noted.

31.5% =1 30% =2

25% =3 or more chronic conditions!

R.L. Hansen, F.L. Mawjee, K. Barton, et al., “Comparing the health status of low-income children in and out of foster care,” Child Welfare, 83 no.4 (2004): 36780.

97, 376 children in the US left motherless by AIDS through 1988. Newborns placed in FC at the time of discharge are 8X more likely to be born to an HIV infected mother.
AAP-Committee on Pediatric AIDS

Sexual Abuse acquired HIV infection was observed in at least 26 children younger than 13 of the 125,000 reported annually.
Children may remain asymptomatic for years or have mild nonspecific symptoms (anemia, poor growth, developmental delay) that are not recognized as secondary to HIV infection.
AAP-Committee on Pediatric AIDS

47.9% 2-14 year olds have emotional and behavioral health problems warranting mental health services.

3x the rate of anxiety disorders. 2x depression 4x substance abuse

6x posttraumatic stress disorder, 2x the rate experienced by returning war veterans!

Pecora P, Kessler R, Williams J, et al. Improving family foster care: findings from the Northwest Foster Care Alumni Study. Seattle (WA): Casey Family Programs;

California Medicaid Expenditures

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53% of all psychological visits 47% of psychiatry visits 43% of the public hospital inpatient hospitalization 27% of all psychiatric inpatient hospitalization

M.D. Simms, H. Dubowitz and M.A. Szilagyi. “Health care needs of children in the foster care system,” Pediatrics 106, no. 4 (2000): 909.

B. J. Burns, S.D. Phillips, H.R. Wagner, et. al., “Mental health need and access to mental health services by youths involved with child welfare: A national survey,” Journal of the American Academy of Child and Adolescent Psychiatry 43 no. 8 (2004): 960-70.

Start earlier, with increased frequency and intensity vs. the general population.

46.3% indicated at least one.

More than 1/5 reported engaging in multiple types. Laurel K. Leslie, M.D, Behaviors in Young Adolescents in the Child
Welfare System, Journal of Adolescent Health 47 (2010) 26–34

12-14y olds are 5.7 x at higher risk than older youth.

By type of maltreatment: Neglected children have overall higher prevalence. History of physical abuse increases risk by 1.33x .
Laurel K. Leslie, M.D, Behaviors in Young Adolescents in the Child Welfare System, Journal of Adolescent Health 47 (2010) 26–34

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25.5% had engaged in sexual intercourse. 16.1% drinking alcohol. 19.5% smoking 13.0% getting into fights 6.6% carrying a weapon in the last 6 months. 7.9% suicidal 4.5% become pregnant or gotten someone pregnant
Laurel K. Leslie, M.D, Behaviors in Young Adolescents in the Child Welfare System, Journal of Adolescent Health 47 (2010) 26–34

Exposure to foster care is associated with increased odds of having 1 laboratory confirmed STI for both male and female youth.

6% homeless adolescents were seropositive.

Kym R. Ahrens, et al. Laboratory-Diagnosed Sexually Transmitted Infections in Former Foster Youth Compared With Peers. Pediatrics 2010;126;e97

Nationally-20,000 age-out of the FC system. 25% of these youth live in California=4,653 in 2008.

50% had a long or permanent placement in FC.

65% need immediate housing upon release. Within 18 months 40-50% become homeless. Nationally, 27% of homeless population have spent time in foster care. 10,875 people age 18-24 are homeless in LA county streets each year. 20-40% are LGBT

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Transitional Housing Temporary shelters Abandoned buildings Cars, Couch surfing Parks, Streets Return to birth families Getting in relationships for shelter.

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46% -complete high school. 10%-enroll in college. <2%-graduate from college.

50%-have developmental delays , 4.5x vs. general population.

50%-high rate of unemployment within 5 y. 1/3 –have incomes at or below $6,000 per year.

42%-(60% female) become parents within 2.5-4 years. 2x more likely to see their own children placed in FC.

Female are 6x more likely to give birth before age 21 vs. the general population.

33% Have no health insurance.

Disproportionately high rates of physical, developmental and mental health problems.

More likely to have a substance abuse condition vs. general population on medicaid.

FY with multiple placements are 5-10x more likely to become involved with the Juvenile Justice System.

25% will be incarcerated within the 1st year.

Providing a medical home for these children/youth requires recognizing the special health care needs including chronic medical conditions, mental health disorders, and developmental and academic delays.

They should be monitored more frequently than the general pediatric population. Identify other professionals in your community who are willing to care for these children .


Children's sense of time

Response to psychological stress Infants  chronic stress= apathy, poor feeding, withdrawal, and failure to thrive.  Acute=temper tantrums, aggressive behaviors, inattention or withdrawal. With age, psychologically disengaged, leading to detachment, apathy, and excessive daydreaming or freeze response.

The presence of at least one caring adult who offers social support and connectedness has been identified as a protective factor for youth across a variety of risk conditions

(Fraser, Kirby, & Smokowski, 2004).

Finally, there is a strong need for practitioners, researchers and policy makers to work collaboratively on efforts toward change. It is only through these multidisciplinary and multicontextual efforts that children and families will receive these services. They require that foster care will live up to its promise to provide a better life for children who have experienced early difficulties.