The 5-year-old had a two-hour meltdown before he came to the pediatrician, where he sat in an exam room mad-faced, arms crossed in front of his kid-sized paper gown.
The reason he was so ornery had little to do with having a checkup, and everything to do with recently moving in with foster parents.
Dr. Lora Melnicoe, who sees about 10 foster children and teens each day at the Connections for Kids Clinic, knew the boy felt powerless, like his life was out of control. So she put him in charge of some decisions: For one, did he want her to listen to his breathing and look in his ears in the room with his baby sister or behind a privacy curtain?
He chose a privacy screen, and the exam began.
The extra time it took to start the boy’s exam is standard at the foster kid clinic inside Denver Health’s Eastside Family Health Center, in Five Points northeast of downtown. Unique in Colorado, the clinic was created because medical staff who examined kids during abuse and neglect investigations were concerned that children were shuffled between doctors’ offices as they bounced through the foster-care system.
Clinic director Melnicoe sees kids who won’t let her touch them. Some refuse to speak.
“The walls go up,” she said. “We’ve had meltdowns in the clinic.”
She hears older siblings, sometimes preschoolers themselves, answer the doctor’s questions about a baby’s eating and sleeping habits as if they have been in charge for years. It’s called “parentified” behavior.
Medical assistant Diane Ford often has to coax kids into getting seven to nine shots in one day because they are so far behind on immunizations. In some cases, they’ve never been to a doctor. And Tina Cutone, a pediatric behavioral health specialist, reads them a brightly illustrated book about life’s uncertainties. It’s called “Maybe Days” and contains the lines “Living in a foster home is usually not the kid’s idea. It is also not the kid’s fault.”
Sometimes all the extra patience works.
“Sometimes, they have to come back another day,” Melnicoe said.
The clinic, a partnership between Denver Health Medical Center and Denver Human Services’ child-welfare division that began in 2007, now sees 150 to 200 foster children and teens each month, a significant portion of the 600 Denver kids in foster homes or “kinship placements” with relatives in any given month.
Foster children typically see whatever pediatrician is convenient for their foster family, meaning that every time they switch foster homes, or go from their biological parents to foster parents and back, they switch doctors. Foster parents in Denver are allowed to take children to their own doctor, but it’s “strongly recommended” by county child welfare caseworkers that foster families use the Connections for Kids Clinic, said Mimi Scheuermann, Denver’s director of child welfare and adult protection.
The clinic provides continuity of medical care for kids whose lives are in turmoil. And, unlike the average pediatrician’s office, the medical staff has experience with abused and neglected children, who not only have higher rates of mental and behavioral problems, but also medical issues.
Foster kids are more likely to have skin diseases and asthma and less likely to have dental and eye exams. The higher prevalence of mental and physical health problems is connected to environmental factors, including nutrition.
Colorado child welfare law requires foster parents to schedule a medical appointment within 14 days of placement and a dental exam within eight weeks. The American Academy of Pediatrics recommends infants in foster care be seen every month and that children get medical checkups every six months instead of annually, as for kids not in foster care.
A statewide review found 62 percent of foster children either received or had a medical exam scheduled within 14 days of placement in 2016, according to Colorado Department of Human Services data.
At the clinic, each foster child is the subject of two “Ages and Stages Questionnaires,” called ASQs, one regarding physical development and the other a social-emotional inquiry. The questionnaire for 2-year-olds asks, “Does your child stiffen and arch his back when picked up?” and “Does you child try to hurt other children, adults or animals?”
The physical development test’s “failure rate” for typical children is 21 percent. For children in foster care, it’s 58 percent.
The questionnaire, usually done at the child’s first appointment, alerts staff if a child needs physical or mental health therapy in their homes. Babies born to mothers who used drugs while pregnant, for example, often have poor muscle tone that requires physical therapy, and need massage to learn to self-regulate and soothe themselves.
Jill Groulx, the clinic’s case manager and a registered nurse, has two photographs of a foster child named Grace in her office, the first taken when Grace first entered care, her limbs like sticks. She was 3 then but the size of an 18-month-old. The second picture shows the girl after her adoption a year later, healthy and smiling.
“What we do is not easy; it’s hard,” Groulx said, grateful that the clinic’s original core staff, all female, has stayed intact. “Sometimes we will go into another room and shut the door and talk, and we’ll cry. Then you dab your eyes and go on to the next patient.”
The clinic in the heart of one of Denver’s toughest neighborhoods is cheery, with a larger-than-life Doc McStuffins Disney character on the wall and decals of Broncos stars Demaryius Thomas and Peyton Manning. Staff know not to say the name of the pharmacy the foster family uses in front of biological parents, who at times attend appointments. Kids are seen directly, with hardly any waiting time.
“They totally get kids in care, kids who have been traumatized. They are very much in tune with what our kids can and cannot do,” said Sister Michael Delores Allegri, who has been taking in foster children for more than 20 years and now has three, ages 1, 2 and 3. “It relaxes them right away when they are nervous.”
Many of the 71 foster children Allegri has taken in had never been to a doctor at all or had not had regular visits. She has cared for kids whose medical care was so “superficial” their medical records said they were “progressing normally” but then they scored eight months behind developmentally on the “Ages & Stages” questionnaire when she took them for their first appointment.
But she understands why.
“The kids’ medical piece was not their mother’s priority — it was whether they are going to have food on the table,” Allegri said.
Children’s medical records from the clinic are entered into the state child welfare computer system, following them if they move. Biological parents can continue bringing their children to the clinic after they’ve returned home.
And knowing their children are attending the clinic while in foster care brings peace of mind to biological parents, said Dr. Kathryn Wells, medical director of Denver Health’s Family Crisis Center, which does exams during abuse and neglect investigations. “We want the families to know that if your child is removed from your care, they are being taken care of,” she said.
Research hasn’t yet been done to determine whether foster children at the clinic are healthier or stay in placements longer, but the clinic has attracted attention from other Colorado counties and states.
Douglas County child welfare officials toured the clinic about a year ago and have set up a “mini” pilot program. Caseworkers now refer foster families in the county to Castle Rock Pediatrics, where Dr. C. Rashaan Ford has a background in child abuse and neglect. The clinic coordinates with the county so a mental health clinician can come to the office and evaluate the child at the same appointment.
The Castle Rock doctor’s office was chosen in part because it accepts Medicaid, government health insurance that covers foster children and other needy Coloradans.
Since February, just 12 foster children have attended the Castle Rock clinic, mostly because the location isn’t convenient for many foster families. Douglas partners with Jefferson and Arapahoe counties for foster placements, meaning kids from Castle Rock could go to a home as far as Arvada or Larkspur.
“We really are in the very baby beginning steps to try to see it is more important to have the close proximity to the pediatrician or is it more important to have the continuity of the pediatrician,” said Douglas County child welfare administrator Ruby Richards.
In Denver, behavioral health specialist Cutone said they see the “shadow side of life” every day but also are inspired by the number of neighbors, teachers and coaches who end up becoming foster parents to help a child. The staff has become a support network for foster parents, who at times are overwhelmed.
Siblings who are separated ask about each other when they come for their appointments if they know their brother or sister goes there too. Teenagers who attended the clinic as foster children and have aged out of the system return to Eastside for doctor visits, and stop in to say hi to the doctors and nurses they used to see.
“We want them to feel comfortable and safe, like this is their medical home,” Dr. Melnicoe said.