Health and Well-Being of Children in Foster Care Placement

Abstract

Improving the Odds for the Healthy Development of Young Children in Foster Care. Dicker S, Gordon E, Knitzer J. National Center for Children in Poverty: Columbia University Mailman School of Public Health. Promoting the Emotional Well-Being of Children and Families (Policy Paper No. 2). January 2002;1–28Children and Family Services Reviews, Part V: Most States Fail to Meet the Mental Health Needs for Foster Children. Huber J, Grimm B. Youth Law News. 2004;Oct-Dec:1–36CWLA Standards for Health Care Services for Children in Out-of-Home Care. Washington, DC: Child Welfare League of America; 1988.Educational Experiences of Children in Out-of-Home Care. Smithgall C, Gladden RM, Howard E, Goerge R, Courtney M. Chicago, Ill: Chapin Hall Center for Children at the University of Chicago; 2004:1–77Fostering Health: Health Care for Children and Adolescents in Foster Care. 2nd ed. Task Force on Health Care for Children in Foster Care, American Academy of Pediatrics, District II, New York State. Elk Grove Village, Ill: American Academy of Pediatrics: 2005Healthy Foster Care America. www.aap.org/advocacy/HFCA/On any given day, more than 500,000 children are living in state-supported foster home care. In the course of a year, more than 800,000 children experience placement in a foster home. Many of these children return home quickly, but for some, placement may extend for years and may involve care in multiple foster homes. Most of the children have experienced serious family dysfunction prior to placement, including exposure to domestic violence and to their parents’ mental health disorders, addiction, or criminal activity. Serious neglect and abuse are the most frequently stated reasons for removing children from their parents’ care. Children entering foster homes have extremely high rates of physical and mental health problems, developmental delays, and educational underachievement. As a group, children in foster care have the greatest combined needs of any group of children in our society.Although foster care generally is a safer alternative than remaining with their family, children almost always perceive removal from their home as traumatic and frightening. Failure to address these issues and to identify and treat the many chronic and pervasive health, mental health, and developmental problems of these children results in continued neglect and escalating problems while in placement. One irony of the foster care system is that so many children fare poorly despite the large number of adults involved in their care, including biologic and foster parents, social workers, child advocates, lawyers and guardians ad litem, judges, teachers, and physicians. This poor result is due largely to the rather narrow focus of the public child welfare system on the resolution of acute crises and its view of foster care as a short-term, intermediate step toward a more permanent placement—either with the biologic parent or in an adoptive family.As society became aware of the problems of child abuse and neglect in the post-World War II era, social workers turned to foster care placement as a “safe haven” for children. Unfortunately, due to limited resources and planning, many children remained in foster care for years, “drifting” from one placement to another, without clear plans for their futures. Health surveys of these children revealed extraordinary needs and frequent failure to receive necessary care while in foster care placement. This increased awareness resulted in changes on various fronts to improve the foster care system.In an effort to reverse the increasing number of children entering foster care, Congress passed the Adoption Assistance and Child Welfare Act (PL 96–272) in 1980, requiring states to make “reasonable efforts” to prevent children from entering foster care and to reunify children in foster care with their families whenever possible. Under the provisions of this law, states were directed to develop a “permanency plan” at the beginning of placement to prevent children from remaining in foster care for indefinite periods of time. Clearly defined permanency goals—return home, placement with relatives, or adoption— had to be established within the first 18 months of placement, and courts were required to conduct periodic reviews of children’s placements and progress toward achieving the permanency goals. Although this law resulted in a significant change in the focus of efforts and achieved some success in reducing length of stay in foster care, the drug epidemic that began in the late 1980s set the stage for a new influx of children into foster care and made permanency planning very difficult to achieve.In 1997, a new federal law, the Adoption and Safe Families Act (PL 105–89), was enacted to prompt more timely permanency planning for children in foster care. Under the new law, a permanency plan must be made for a child in foster care no later than 12 months from the child’s entry into care, and a petition to terminate parental rights must be filed to free the child for adoption when a child has been in foster care for 15 of the most recent 22 months (with some exceptions). Adoption is now viewed as an important option for children in foster care.Children who live with extended family members face many of the same issues as those who enter foster home placement with nonrelatives. These “kinship care” arrangements historically have been informal, but with the increased number of children entering the public child welfare system, state support for kinship placements has grown considerably. Many argue that placement among relatives lessens the trauma of placement and ensures that children will not be removed from familiar surroundings, cultural contexts, and values. However, licensing requirements for kinship providers often are less rigorous, and children in kinship care placements generally receive less attention from social workers than do children in nonrelative foster homes. Children in kinship care arrangements often have more unsupervised contact with their biologic parents. In general, kin caregivers are older, poorer, and receive less assistance in accessing services for the children in their care.In recent years, many study groups have recommended improvements in the provision and coordination of services children receive while in placement. Increased attention is being paid to the educational, mental health, and social supports needed by older children and adolescents to prevent their exiting foster care only to become unemployed or homeless or to enter the adult mental health or criminal justice systems. Among youths surveyed within the first 12 to 18 months after “emancipation” from foster care, 27% of males and 10% of females had been incarcerated at least once. The McKinney-Vento Homeless Assistance Act, reauthorized in 2002, requires school districts to allow homeless students (under which children in foster care can qualify) the option of staying in their school of origin until the end of the academic year, even if the school district must provide transportation.Health services research has noted that children in foster care use a disproportionate amount of health and mental health care compared with children from similar social and economic backgrounds and that these high-level services are directed to a small minority of children in placement. On the other hand, children who receive primary and preventive health services show striking improvement in health, development, and educational measures while in foster care placement. The pediatrician has the opportunity to provide timely and appropriate anticipatory guidance for families caring for children in foster care, with the expectation that health status can be maintained and even improved while in out-of-home care.Pediatricians can advocate for children in foster care to receive needed services. Ideally, the pediatrician obtains a thorough history and performs a comprehensive health evaluation when a child enters foster care. The American Academy of Pediatrics (AAP) has adopted health care standards for children in foster care that recommend direct evaluation of these children at more frequent intervals than nonplaced children at each age. All children entering foster and kinship care also should undergo mental health, behavioral health, and developmental evaluations. The pediatrician should communicate directly with the caseworker to ensure that ongoing issues are addressed, even if the child is placed in a different foster home or leaves foster care to be reunited with his or her family. The pediatrician also may refer aging kinship care providers to community resources to assist them in caring for the children in their custody.In response to the unique health needs of these children, several models of health care delivery and intensive health case management have developed around the country. Central to these efforts is the recognition that children benefit most when their problems are identified and treated early in placement and when they receive continuous health care from a “medical home.” However, frequent changes in foster homes during foster care often present a formidable barrier to achieving continuity of health care. Some medical home models provide centralized services, incorporating both primary and specialized health care needs (such as through a managed care or health maintenance organization structure). Other models provide a comprehensive health assessment on entry to foster care, with coordination of ongoing services to a wider network of providers as needed (such as through a traditional fee-for-service structure). The most successful health care programs for children in the foster care system have strong support from the local child welfare administration and public school systems.Despite all that has been learned about children in foster care, they remain an underserved population who receive fragmented and crisis-oriented services. Health-care financing structures do not support the added attention these children require to receive proper diagnosis and treatment, and child welfare programs lack the resources to coordinate care across the many professional and administrative systems to which these children belong. The AAP is taking the lead in addressing these complex issues through its Healthy Foster Care America Initiative. Over the next several years, the AAP will sponsor focus groups of key partners in the health, mental health, education, legislative, legal, and child welfare systems to find innovative strategies for improving the well-being of children while they remain in foster care.It is in the broadest context of caring for children that pediatricians can play a key role in the lives of their patients in foster care. No other professional is in the position to evaluate the wide range of these children’s issues or to influence the diverse array of care providers. Foster parents, social workers, attorneys, judges, and policy makers value the insights and advice of pediatricians. By implementing a process of early identification and treatment of health and mental health problems, with a strong emphasis on continuity of care and preventive health measures, pediatricians can help ensure that a child’s time in foster care promotes positive development and well-being.

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