Epidemiology

The number of children in foster care worldwide is unknown, although it has been estimated that 8 million may be in foster and residential care. In 2007 in the USA, approximately 783,000 children spent some time in foster care; 496,000 children were in foster care on any given day. These numbers represent a downward trend since 1999 when the daily average of children in care was 567,000. This decrease results from fewer admissions and more reunifications, placements with relatives or close family friends (kinship care), and adoptions of children who had been in foster care (Chapter 34). There may be up to 4 times as many children in informal kinship care as in certified foster care.

A large number of children entering foster care in the USA are young; approximately 40% of children entering foster care are under the age of 5 yr. The majority are white (46%); significant percentages are black (28%) and Latino (17%). Children continue to remain in care for significant periods of time; the average for children who enter foster care is about 18 mo. Importantly, about 44% of the children in foster care have been in foster care for ≥2 yr.

Only about 50% of children achieve reunification. Annually, approximately 50,000 children (17%) are adopted out of foster care. Among remaining children, 11% return to extended family, 9% emancipate, 5% enter into long-term state guardianship, 2% run away, and 2% transfer to other institutions. In 2006, there were 509 deaths in foster care.

Most children live in foster family or certified kinship family care. Approximately 18%, mostly adolescents, live in group homes or residential settings. The average length of stay in foster care has decreased from a high of over 5 yr in the 1980s to 28 mo. Currently, 42% of children stay less than 12 mo, 34% spend 1-3 yr, and 29% remain in care for 3 yr or more. Important predictors of the number of foster care placements for a child include: severe behavioral or developmental problems, larger sibling group size, and longer time spent in foster care.

Legislation in the USA

In the USA, the Adoption and Safe Families Act (P.L. 105-89) passed in 1997 requires that a permanency plan be made for each child no later than 12 mo after entry to foster care and that a petition to terminate parental rights typically must be filed when a child has been in foster care for at least 15 of the previous 22 mo.

The Foster Care Independence Act of 1999 (P.L. 106-169) was intended to promote the successful transition of the nearly 20,000 youth emancipating from foster care annually by providing states with additional funding for independent living services. Within 12 mo, many have experienced at least 1 homeless night. Within a decade after leaving foster care, less than half have a high school degree, most are living in poverty, and there are high rates of post-traumatic stress disorder and depression.

In 2008, the Fostering Connections to Success and Increasing Adoptions Act (P.L. 110-351) was enacted. This law provides increased financial incentives for kinship caregivers and adoptive families. Equally important, this law requires states to develop health care systems to improve the health outcomes of children in foster care.

Early Childhood Trauma Leads to Poor Health Outcomes

Children entering foster care have frequently experienced early childhood trauma. More than 70% have a history of abuse, neglect, or both. Over 80% have experienced significant domestic and/or community violence. Birth parents have high rates of mental illness, criminal justice system involvement, substance abuse, unemployment, and cognitive impairment. Many children have had prenatal substance exposure, multiple caregivers of varying quality, and are from families with long involvement with child protective services.

Removal from the family of origin is usually traumatic for children. A few children experience relief at removal from a chaotic, abusive, or dangerous home. Nonetheless, most children miss their family, worry about their parents and siblings, and long for reunification. Previous traumatic experiences are compounded by the separations and feelings of loss surrounding removal, unpredictable contact with birth parents, placement changes, and the process of terminating parental rights.

Early childhood trauma is correlated with poor developmental and behavioral outcomes. Early trauma and chronic stress affect the neurobiology of the developing brain by inducing long-standing hyperreactivity of corticotropin-releasing factor and neurotransmitters. These changes adversely affect the development of areas of the brain involved in attention and emotional regulation, and can result in shortened attention span, hyperactivity, poorer cognitive function, aggression, and dissociation, problems encountered frequently among children in foster care.

Health Issues

A variety of factors act as barriers to the health care of children in foster care. Most public and private child welfare agencies do not have formal policies or arrangements to provide health care services and rely on local physicians and/or health clinics funded by Medicaid. It is often difficult to obtain complete information on the health histories of children who enter foster care because they often have erratic contact with various health care providers before they enter foster care, and social workers are not always able to obtain detailed information from biological parents at the time children enter care. Once children enter foster care, there is often a diffusion of responsibility regarding obtaining health care services. Foster parents are often given very little information about the health care needs of the children for whom they are caring, but they are typically expected to decide when and where children receive health care services. In some cases, social workers may oversee the health care of children in foster care, but coordination with health care providers is often lacking. Uncertainty as to who may make health care treatment decisions for children may further delay health care or result in the denial of health care services.

Multiple childhood adversities are compounded by the receipt of fragmented and inadequate health services before placement into foster care. As a result, children enter foster care with a high prevalence of chronic medical, mental health, developmental, dental, and educational problems (Table 35-1). Consequently, they are children with special health care needs. The greatest health care need of this population is for mental health services to address the impact of trauma, loss, and unpredictability. These children have higher rates of asthma, growth failure, vertically transmitted infections, and neurologic conditions than the general pediatric population. Obesity exceeds failure to thrive as the most prevalent nutritional disorder in foster care. Adolescents need access to reproductive health and substance abuse services. Up to 60% of young children have a developmental delay in at least 1 domain. Educational difficulties persist despite improvements in school attendance and performance for many children after placement in foster care. Almost half of children in foster care receive special education services.

Health Care for Children and Adolescents in Foster Care

The American Academy of Pediatrics (AAP) and Child Welfare League of America published updated general guidelines for the health care of this special needs population in 2007. The AAP has also published detailed health care standards for children in foster care. Children should receive health care services in a medical home setting where they receive comprehensive health care that is continuous over time (Table 35-2). All health needs should be addressed compassionately and with an understanding of the effects of past trauma and ongoing uncertainty on a child’s health and well-being. Pediatricians should see children early and often when they first enter foster care. This provides an opportunity to identify all of a child’s health issues, support the child and foster parent through a major transition involving grief and loss for the child, and assess the child’s adjustment to foster care.

Table 35-2 PEDIATRIC MEDICAL HOME FOR CHILDREN IN FOSTER CARE

CHARACTERISTIC	APPLICATION IN FOSTER CARE
Comprehensive health care	Perform comprehensive admission assessment upon entry Ensure access to mental health, developmental, and dental services Screen and refer as needed for abuse and neglect

Coordination of care Compassionate care Understand and educate children, families, and other health care professionals on the impact of early childhood adversities and the uncertainties of foster care Child-centered and family-focused care Continuity of care Invite children to remain patients throughout their stay in foster care Cultural competence Extend this concept to include the microculture of foster care Understand the roles of caseworkers, foster parents, law guardians, etc. Accessibility Create a welcoming environment for children and all of their families (birth, foster, kin, preadoptive)

The AAP recommends that every child in foster care have comprehensive medical, dental, developmental, and mental health assessments within 30 days of entering foster care. Children under 6 yr of age should have a comprehensive developmental assessment, and older children should have a comprehensive educational assessment. The primary care provider should help caseworkers and foster parents obtain and interpret the results of these assessments. Pediatricians should share health information with the child’s caseworker and foster parent. The caseworker should provide consents for health care and any available health history, and encourage the appropriate involvement of the birth parent.

Foster parents are the major therapeutic intervention of the foster care system, and pediatricians should provide them with appropriate education and support. Important topics include parenting children through transitions, providing a consistent and nurturing environment, and help children heal from past adversities (Table 35-3). Behavioral and emotional problems should be described within the framework of the child’s trauma history to remove blame and promote healing. Pediatricians should help parents focus on a child’s strengths and help each child develop skills needed for a successful life.

Table 35-3 ANTICIPATORY GUIDANCE FOR CHILDREN IN FOSTER CARE

SITUATION	ANTICIPATORY GUIDANCE FOR FOSTER PARENTS
Preparing for visits	Explain visitation process Send familiar object with child to visit Have child draw picture to give birth parent Reassure child that foster parent will be there when child returns from visits
Returning from visits and other transitions	Establish re-entry rituals Greet child warmly and help with unpacking Read a book or share a healthy snack
Relationship with birth parent(s)	Encourage caseworker to have birth parents keep child’s rituals and routines consistent with those in foster home (vice versa when appropriate) Focus on birth parent’s positive qualities; maintain a neutral affect
Building on child’s strengths	Encourage participation in normalizing activities (such as hobbies or sports) “Catch the child being good”
Preparing for court dates	Have caseworker or law guardian explain purpose of court hearings to child in simple terms
School	If changing schools, visit school together and meet the teacher Check in regularly with child’s teacher
Adolescent	Encourage responsible decision-making Teach driving when age and developmentally appropriate Encourage teen to seek employment and teach job skills Help teen to identify mentors and focus on the future