Necessity of a national guideline for the management of children in foster care

There are around 400 children’s homes in Sri Lanka and nearly 2400 children receive foster care. Children in foster care homes suffer secondary victimization and life fatal events. Some countries such as USA, UK and India have developed Guidelines for the management of foster care children but in Sri Lanka we do not have such guidelines. Attention is drawn to the causes of death of 16 children at the index foster care home since year 2001. To reduce secondary victimisation and morbidity and mortality of children, a national guideline for the management of children in foster care homes should be developed at the earliest. Corresponding Author: Vidanapathirana M, Email:<mudithavidana@sjp.ac.lk> Received: June 2016, Accepted revised version September 2016, Published: October 2016 Competing Interests: Author has declared that no competing interests exist Introduction The most common reasons for the placement of children in foster care homes are negligence, abandonment and child abuse. In addition, poverty, homelessness, violence at home, lack of medical care, parental substance abuse, parental mental illness and premature births are often present. According to the Probation Officers Association of Sri Lanka, in January 2016 there were 414 children’s homes and 2479 children receiving foster care in Sri Lanka. The main reasons for placement were broken families and referral by courts. Although in foster care, 31% had both parents, 51% had one parent and 18% had neither. The UNICEF Convention on Rights of Children (CRC) recognizes children’s rights to the highest attainable standard of health and access to health care services. However, most of the local care providers do not receive special training to care for foster children. Due to the prevailing conditions at children’s homes, children are at risk of physical, mental and developmental health problems, needing special physical and psychological care. Only Rs.20 is allocated for the care of one child per day to some homes in Sri Lanka. Lack of financial and health care resources impedes the care of these children. Therefore, children living in foster care homes continue to suffer and are at risk of dying in foster care. Forensic pathologists are often involved in investigations if any death occurs in foster care homes as children may be under custody or because questions may be raised against the authorities in such circumstances. Neglected children often fail to establish an attachment to a caretaker. Most often, the Journal of the Postgraduate Institute of Medicine 2016; 3:E29:1-5 doi: http://dx.doi.org/10.4038/jpgim.8093 2 relationship between caretaker and child is not affectionate and may lead to risk of abuse. Therefore, forensic pathologists play an important role in medico-legal management; identifying the hidden forms of abuse, providing legal recommendations and advising measures for prevention. Problems faced by foster care children are poorly addressed in Sri Lanka and the following case discussion addresses the gravity and consequences of lack of care at the index foster care home. Since year 2001, 16 deaths were reported in this institution and in 2015 a two and half year old child died by falling into a bucket of water. The CCTV evidence of the circumstances was available as CCTV surveillance system had been installed in 2010. (Figure 1) Initial stage of falling into water bucket Mid stage of falling Child struggling in water Child has drowned


Introduction
The most common reasons for the placement of children in foster care homes are negligence, abandonment and child abuse 1 . In addition, poverty, homelessness, violence at home, lack of medical care, parental substance abuse, parental mental illness and premature births are often present 1 . According to the Probation Officers Association of Sri Lanka, in January 2016 there were 414 children's homes and 2479 children receiving foster care in Sri Lanka 2 . The main reasons for placement were broken families and referral by courts. Although in foster care, 31% had both parents, 51% had one parent and 18% had neither 2 . The UNICEF Convention on Rights of Children (CRC) recognizes children's rights to the highest attainable standard of health and access to health care services 3 . However, most of the local care providers do not receive special training to care for foster children 2 . Due to the prevailing conditions at children's homes, children are at risk of physical, mental and developmental health problems, needing special physical and psychological care. Only Rs.20 is allocated for the care of one child per day to some homes in Sri Lanka 2 .
Lack of financial and health care resources impedes the care of these children. Therefore, children living in foster care homes continue to suffer and are at risk of dying in foster care. Forensic pathologists are often involved in investigations if any death occurs in foster care homes as children may be under custody or because questions may be raised against the authorities in such circumstances. Neglected children often fail to establish an attachment to a caretaker. Most often, the relationship between caretaker and child is not affectionate and may lead to risk of abuse 4 . Therefore, forensic pathologists play an important role in medico-legal management; identifying the hidden forms of abuse, providing legal recommendations and advising measures for prevention.
Problems faced by foster care children are poorly addressed in Sri Lanka and the following case discussion addresses the gravity and consequences of lack of care at the index foster care home. Since year 2001, 16 deaths were reported in this institution and in 2015 a two and half year old child died by falling into a bucket of water. The CCTV evidence of the circumstances was available as CCTV surveillance system had been installed in 2010. (Figure 1 In the index case of death due to drowning, the CCTV footage was helpful to decide the manner of death. The autopsy revealed multiple pinch marks on this child's body including the ear lobes and findings compatible with accidental drowning.
One of the authors visited the scene and had discussions with the employees of the index children's home and relevant authorities. It was revealed that an employee had to feed, clean and care for 8 or more children during a duty shift. The staff said that they did not receive adequate information regarding the children's health status although there are children with special needs and disabilities such as epilepsy, cardiac problems, cleft palate and cerebral palsy and bedridden children. There was no procedure to convey information relevant to the child's health status and management when handing over at the end of the shift. The staff identified serious problems for the first time only when the child became blue, had difficulty in breathing or had a convulsion etc.
In addition, it was revealed that CCTV cameras had been installed in verandahs, bathrooms, the kitchen and common sleeping areas of this home in 2010. The staff said that the incidence of diarrhoea had reduced after installing CCTV cameras. This was attributed to the adoption of more hygienic procedures during preparation of milk consequent to surveillance by authorities, the deterrent effect of CCTV and the ability to review past events. However, some workers continued to assault children, especially the bedridden, after covered the CCTV cameras with clothes or mosquito nets. There were 16 deaths reported from this index foster care home since 2001 details of which are given in table 1.

Discussion
Most of the causes of death listed above are preventable by immunization, early recognition and treatment. Studies have shown that respiratory problems, developmental delay and skin conditions are common medical conditions found in children in foster care on admission 5 . Lack of information regarding past medical history and immunization status, may lead to illness and even death. Lack of trained staff and resources may lead to unnecessary deaths 2 . Training is especially important when looking after children with epilepsy, cerebral palsy and cleft palate as they are at risk of aspiration and pneumonia. Even though these homes are called 'safe homes', there is no assessment of the safety of the environment. In the index foster care home there were many places which posed a risk of electrocution, drowning and falling from a height. Ultimately, the 16th death was due to drowning in a bucket of water.
In addition, poorly managed foster care children are at high risk of future consequences such as substance abuse and poor mental health and, in 18 -42%, of incarceration in adulthood 6 . In addition, long term loss of productivity and danger to the safety of society occurs.
In Sri Lanka, there are no guidelines for care of foster care children. The American Academy of Paediatricians has developed guidelines for the USA 7 . In India, in 2015, guidelines for foster care were developed by the Ministry of Women and Child Development 8 . In UK, the publication "Children in Care Legislation, Policy and Guidance" is specifically related to foster care children 9 . Existing evidence warrants the development of a multidisciplinary guideline for Sri Lanka, to regulate the admission, management and follow up of children in foster care.
The guidelines proposed by the authors are as follows: 1. An Initial health screening including assessment of vital signs, anthropometric measurements, examination of all body surfaces for signs of abuse, inspection of genitalia and anus done preferably within 24 hours. The goal of this screening is to identify acute and chronic medical and mental health problems and to provide early attention. Delaying the process can lead to morbidity and mortality of children. 2. A comprehensive health assessment done preferably within one month with planned follow-up and review. The ultimate goal is to optimize the physical and mental development of the child and review the child's adaptation to the new environment. All medical and social information should be reviewed and immunization should be completed. 3. A comprehensive mental health assessment done preferably within three months as longer term observation is required to perform a reliable assessment. The child's fine and gross motor skills, language and social skills should be reassessed. 4. A multidisciplinary management plan to review children periodically to prevent secondary victimization and to reduce preventable deaths among foster care children. The multidisciplinary team should include legal authority, child welfare authority, forensic medical practitioner, other medical representatives (paediatrician, psychiatrist etc), child rights promotion officers and the guardians or parents of the child, if available. The team should meet regularly to review and to plan the management of each child. 5. Technical and skills improvements to the foster care home should be done periodically. Establishment of modern surveillance methods such as CCTV should be made mandatory. Frequent training programs must be organized in order to educate and develop special skills among foster care workers.

Conclusions
The development of a national guideline for the management of children in foster care homes in Sri Lanka is a dire need to reduce secondary victimization and further abuse within foster care homes and to reduce morbidity and mortality of such children.