Doctor, Doctor!

Quality medical care is important for all kids, but is even more so for kids in foster care. Our kids come to us with unknown histories- both personal and family. They may or may not have ever seen a Doctor or been immunized. Their Mother may or may not have had prenatal care. She may or may not have abused alcohol or other substances while pregnant. Then they have experienced abuse or neglect. The impact of that trauma impacts the kind of medical care they need once they are in your home.

My life is simplified by the medical system set up by my agency. There is one designated Foster Care Clinic that all foster families in the county must bring their kids to. They are trained and really familiar with this specific population; are comfortable writing letters for court, and getting us set up with WIC and Early Intervention Services. For Specialists, there is a Children's hospital in the City that is minutes from the clinic. We are referred there for cardiology, gastroenterology, neuro- really, all the "ology"s. Foster parents in our area know that these providers will accept the Medicaid and Managed Care HMO plans that our kids are on. I do not take for granted that this is a luxury foster parents in other areas do not have.

Other foster parents must find a Doctor to take their child, and take their child's insurance, very quickly after placement. They must explain the situation as they know it and have the child evaluated. I don't even know how consents work for that kind of stuff. With our foster care clinic, they have access to our child's county caseworker and can pretty easily get insurance and any history the parents have shared with the caseworker. I imagine the information would be passed through the foster parent. That seems like a lot of pressure.

Our visibly injured and fragile kids are of course going to need specialists, therapies, home nurses, etc to get them well and provide appropriate care. I am sure that getting those kinds of care plans in place, while overwhelming, is probably obvious and unquestioned with the Doctor you choose.

It's the kids with the invisible wounds that need the less obvious care plans. I had child who had classic Attention Deficit Hyperactivity Disorder. Every checklist you can imagine indicates this diagnosis. The teachers say he can't stay in his chair- he's falling on the ground multiple times per day. He is impulsive- touching other children and speaking out instead of raising his hand at circle time. He always gets the first 2 answers correct on every paper and test before rushing the rest and making answers up. His play is loud and fast moving- always with cars crashing and lots of roaring and sound effects. I know that most Doctors and typical parents would take it for what everyone sees- ADHD.

Fortunately he doesn't have most Doctors or a typical parent. What I was able to tell them when they asked me the right questions is that he also bites the inside of his lip and his fingernails, picks his cuticles, and scratches behind his ear until it bleeds. This usually happens at bed time and keeping lights on or doors open makes no difference. He also can sit through dinner at home without falling out of his seat. Homework is a breeze where I rarely have to correct his answers, but may have to focus his attention. I have watched him spend 20 minutes solid doing a puzzle or making a million paper airplanes for everyone he knows. We have also seen sudden mood swings that end in angry violent tantrums. There is always an obvious reason that makes him mad, but no obvious event that snap out of it- which he also does quickly. With time, there have been less frequent episodes like this, but they seem to get more intense each time. A nurse practitioner with experience in treating abused kids knew to get him a full psychiatric evaluation which showed Post Traumatic Stress Disorder. PTSD- not ADHD. Where another provider and another parent could have seen a hyper kid- we were actually dealing with a very anxious kid.

Any person, but especially a child, who is dealing with intense anxiety is not going to respond well to a carpet full of squirmy preschoolers or to a routine change brought on by new children in his house. The plan was not to go right for the behavior modification or hyperactivity meds, but to focus on stress management and identifying feelings. Giving words to what was happening in his head was of utmost importance. The idea was that once the anxiety that had become his baseline was brought down, he'd have an extra second to make a better behavior choice. We ended up with 2 different kids of therapists- both who work with trauma, but in different ways. One came to our home and the school and uses a lot of art and movement in her sessions. She had him color satisfied and dance angry. The other was an office based therapist who used toys at a table to start conversations about specific things that had happened in the child;'s past. Therapist 1 encouraged our participation with the child while Therapist 2 insisted he see the child and us separately.

Then we had a baby who was colicky. Spit up everything and miserable. I was genuinely concerned that this child would end up shaken if he went home because he was exhausting and nothing soothed him. The parents insisted he was allergic tot he formula. I agreed. He was cranky all the time because his tummy was upset. The nurse practitioner at the clinic was steadfast that we keeping his formula and feeding schedule the same. She was positive that this was normal for the reason why he was in care- even though the books all say that a child with his condition should be recovered by that time. She gave me some great tips about attachment and sensory soothing. I did end up wearing that baby strapped to my chest for 12 week. He slept in baby hammock that I borrowed from another foster Mom.  In less time than I thought- he turned into the happiest 4 month old ever. Same formula, same routine- no more hammock. If I was dealing with a Doctor who wasn't used to withdrawing babies, we could have been adding rice or using stinky soy formula when the kid only needed a moby wrap and some time.

When we had a baby who was born at 30 weeks at less than 4lbs, the Doctor wrote a letter to the judge explaining why it was not a good idea to make that baby do jail visits. I know other Doctors would have been hesitant to be so bold and put their name on something that could require them to be involved in a court case. That same Doctor for a different baby had already taken pictures of the child's large Mongolian birthmark that covered his bottom four months before his parents noticed it and accused us of bruising him. It was very fortunate for us in that moment that this Doctor is always thinking about court and the ramifications this child's medical care could have legally for the child themselves, and their bio and foster families.

As Foster parents, we need to be sure that the Doctors we choose for our children aren't just the closest pediatrician to our home that accepts Medicaid. We can't look at the Dr. like we would for our biological children. If my biological child was coming home with school reports like the child I mentioned earlier- it would be completely appropriate to move forward with an ADHD diagnosis. All of our kids come into care with some sort of special need- whether is is a need to have someone understand how trauma has changes the way their brain processes emotions and information, or a need to have  a feeding tube placed after a Failure to Thrive Diagnosis.  Finding the right Doctor is only the first step in our list of responsibilities, though. We also have to be informed parents. It is hard with foster care, because we don't get to consent for treatment. We don't get to deny a providers plan if CPS doesn't understand our objections. That doesn't mean we can't ask questions. It doesn't mean we don't seek second opinions, It doesn't mean we don't fight for sedation at the dentist appointment that makes your child dysregulate and act out aggressively. We have to be aware of the options and ask that no stone be left unturned.

Our kids who have experienced significant amounts of pain or who have not had the most caring adults responsible for them are not always going to be upfront with their symptoms. While it's important that we stay on top of our Doctors, we also have to stay on top of our kids. I had an incident with Baby 4 about a year ago. He was getting ready for a visit, so I sent him to the bathroom before we left. He yells, "Mom! My pee is red!". When I went in he was peeing straight blood- bright red and thick. I obviously freaked out and took him right to the Emergency Department. He had a urinary tract infection- not a terribly big deal- except his was really bad. The Doctor said he had to have had it for a while and it had to have been causing him pain. Whe  we asked him, he first insisted he never had any pain. He said he noticed his pee was brown, but he thought it was poop in the toilet that someone had forgotten to flush. Then it was red, but sometimes he sits to pee and poop at the same time, so it could have been his poop. He didn't think he had to tell me. He was 6 yrs old at the time- and completely independent in the bathroom. I never thought to ask about pain when using the bathroom or what color his urine was. A kid who hadn't experienced such a high level of pain would have been moved enough to say something. A kid who wasn't used to weird medical things going on in his body would have seen the urine change as something alarming. After asking again about any discomfort or pain, 4 said that he did feel like he had to go pee all the time and is did hurt to pee but he's brave. I check in now with him a couple times per week to go over any new feelings in his body- aches, pains, whatever. He's had to deal with a lot of medical interventions and pain on his own, and now I have to teach him to trust me to help him with these things.

I'm continuing this topic tomorrow with a post on psychotropic drugs prescribed to children in foster care.