The foster care system in America has evolved as a means of providing protection and shelter for children who require out-of-home placement.1 It is designed to be a temporary service, with a goal of either returning children home or arranging for suitable adoptive homes. In recent years, child welfare agencies have been directing greater efforts toward supporting families in crisis to prevent foster care placements whenever feasible and to reunify families as soon as possible when placements cannot be avoided. Increasingly, extended family members are being recruited and assisted in providing kinship care for children when their biologic parents cannot care for them. However, during the past decade the number of children in foster care has nearly doubled, despite landmark federal legislation designed to expedite permanency planning for children in state custody.2 It is estimated that by 1995 more than 500 000 children will be in foster care.3 In large part, this unrelenting trend is the result of increased abuse and neglect of children occurring in the context of parental substance abuse, mental illness, homelessness, and human immunodeficiency virus infection.4 As a result, a disproportionate number of children placed in foster care come from that segment of the population with the fewest social and financial resources and from families that have few personal and limited extended family sources of support.5 It is not surprising then that children entering foster care are often in poor health. Compared with children from the same socioeconomic background, they suffer much higher rates of serious emotional and behavioral problems, chronic physical disabilities, birth defects, developmental delays, and poor school achievement.6-13
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