In the 17th annual Child Fatality Review Report, the DC Child and Family Services Agency (CFSA) disclosed the death of a 9-year-old female involved in the foster care system from an asthma-related complication in 2021. While asthma is a serious pediatric condition, affecting roughly 6.5% of children aged 0-17, it is one that can be successfully managed in the outpatient setting. However, children in foster care with chronic medical conditions face an uphill battle when it comes to maintaining their health. Barriers to accessing consistent medical care include frequent disruptions to the continuity of care and shifting legal rights (for example, who is legally able to consent to medical treatment). Additionally, 65 percent of children in foster care experience more than one foster care placement, and research suggests that placement stability plays a role in physical and mental health outcomes.

Breathing consistency into foster care

Health challenges within the foster care system are especially relevant to children with asthma, as historically the prevalence of asthma is nearly twice as high among children in foster care compared to those uninvolved in the foster system. Appropriate asthma treatment requires consistent care with a provider who is knowledgeable of the child’s health history, current medications, asthma triggers, and disease progression, all of which can be difficult to maintain if a child in foster care is frequently moving between placements and providers. As a result, children in foster care with high rates of displacement may be at a higher risk of negative health effects related to disruption of their medical care. Additionally, trauma, times of transition, and stress have all been associated with an increased risk for developing asthma, as well as the frequency of asthma exacerbations and overall disease severity in foster children already diagnosed with asthma. If not addressed, chronic health conditions like asthma can have immediate and long-term negative health implications, especially for children in foster care. Mitigating the challenges this unique population faces should involve better streamlining of medical information between foster parents, social workers, and providers, as well as ensuring the home environment meets each child’s medical needs.

Although many foster care placements are temporary, for the 810 children served by Washington D.C.’s foster care system in 2021, the average time each child spent in foster care was more than two years. The majority (52 percent) of children served by the District of Columbia’s foster care system reside in Wards 7 and 8, two historically underserved wards. Unsurprisingly, a recent study on pediatric asthma in D.C. found significantly higher rates of ED visits for children with asthma residing in the Southwest and Southeast regions, where Wards 7 and 8 are located.

Ensuring the safety of our most vulnerable

The American Academy of Pediatrics recommends prioritizing the establishment of a new medical home to provide “continuous, comprehensive, and coordinated care” if the child is unable to continue receiving medical care from their original provider. We propose additional recommendations to ensure the safety and well-being of children in the foster care system suffering from chronic medical conditions, including asthma. Drawing on the current systems in place while taking into account successful interventions implemented in other states, we propose three recommendations for the foster care system in Southeast Washington, D.C. that emphasize preparedness, prevention, and continuity of care for children with asthma and other chronic medical conditions.

First, we recommend expanding foster parent training. In order to become a foster parent in Washington D.C., the Child and Family Services Agency requires prospective foster parents to take a training course, undergo a home check, and complete a background check. The training consists of two parts: pre-service training and in-service training, both requiring 30 hours of courses. The pre-service training, taught by the Child Welfare Training Academy, covers developmental needs, cultural and religious awareness, behavior management, first aid, CPR, and more. The in-service training allows foster parents to choose courses pertaining to their foster children, including attachment, grief and loss, and fetal alcohol syndrome. However, none of the available training includes detailed courses on managing chronic conditions in children within the foster care system, which is concerning given that 50 percent of children in foster care have chronic health problems and 10 percent are “medically complex.” To increase foster parents’ awareness of the complexities of managing asthma and other chronic conditions, we recommend requiring a general medical care training module. This should include both day-to-day management, such as medication administration (e.g. proper inhaler usage, insulin injections, EpiPen use, etc.), as well as managing medical emergencies like anaphylaxis, asthma exacerbations, hyperglycemia, and other acute health crises. Given the high likelihood of fostering a child with asthma or another chronic medical condition, this training would ensure that foster parents are prepared to care for them.

Second, we recommend requiring smoke-free homes for children in foster care. Tobacco smoke is a major asthma trigger, and enforcing a smoke-free environment during primary home inspections could help alleviate the impact it has on a child’s health. The home inspection component of a foster parent application involves examining the home for safety and health hazards, sanitation, proper ventilation, and proper storage of medications. Expanding these guidelines to include the requirement of an entirely smoke-free home, which is the case in about half of the United States but has not yet been implemented in Washington D.C., would continue to improve the home environment for children with asthma. However, this does not have to be done at a state or federal level: Georgia’s Division of Family and Child Services (DFCS) designed a program to educate foster and adoptive caregivers on the importance of a smoke-free home. An evaluation of this program specifically stated that participants felt they gained knowledge on the dangers of secondhand and thirdhand smoke, as well as the benefits of a smoke-free home. This is an example of ways in which the foster system itself can implement a policy to improve home health without having a state or federal mandate in place (as Georgia does not prohibit smoking in foster homes), and in this case, is an intervention especially relevant to asthma exacerbations.

Finally, it is necessary to address the barriers to medication adherence and continuity of care for children moving between foster homes. In recent years, California introduced the mandatory use of Health and Education Passports (HEP) for children in foster care. This resource acts as a centralized hub of information accessible to a foster child’s social workers, medical professionals, and foster parents. By creating a database of up-to-date information accessible at any time, the HEP mitigates the disruption of documentation that frequently occurs as a child moves between homes or medical systems. To improve care for children with chronic medical conditions in the Washington, D.C. foster care system, implementation of a similar “passport” system would ensure that foster parents and treating medical providers can access the medical information they need – including medication lists, allergies, medical history, and emergency protocols – to minimize disturbances resulting from placement and improve the overall health of children with asthma and other chronic health conditions.

To prevent another tragic – yet avoidable – death from an asthma-related complication within the foster care system in Washington, D.C., a multi-pronged approach must be taken to address the home environment, continuity of care, and foster parent preparedness. Although we cannot undo all of the stresses associated with the foster care system, we can promote evidence-based recommendations to alleviate the burden of asthma for foster care-involved youth and ensure that America’s most vulnerable children are in safe hands.

About the authors

	Alisa Dewald is a third-year medical student at the George Washington University School of Medicine and Health Sciences. She graduated from the University of Michigan in 2021 with a B.S. in Biomolecular Science and a minor in Urban Studies. Her research interests center on the intersection of housing and health disparities, and she hopes to care for people experiencing homelessness as a physician.
	Kara Hom is a third-year medical student at the George Washington University School of Medicine and Health Sciences. Before she started her journey into medicine, she studied biology at Washington University in St. Louis and worked at Children's National Hospital conducting clinical research in the Emergency Department. She is very passionate about teaching and working with kids, teens and young adults!
	Kathleen McCarthy is a third-year medical student at the George Washington School of Medicine and Health Sciences. She graduated from George Washington University with a Bachelor’s in Public Health.
	Cameron Staubs-Friedman is a third-year medical student at the George Washington School of Medicine and Health Sciences. She graduated from William and Mary with a Bachelor’s in Biology.
	Michael Taylor is a third-year medical student at the George Washington University School of Medicine and Health Sciences, with a scholarly concentration in Community and Urban Health. His professional interests include injury prevention and pediatric medicine with a focus on protective factors and adverse childhood experiences. He assists with research at the Center for Community Resilience and the Early Childhood Innovation Network.

**Feature photo obtained with a standard license on Shutterstock. 

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