Foster and Kinship Care

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. On September 11, 2015, approximately 427,910 children in the United States resided in foster care, representing a slight increase since the nadir of 397,301 reached in 2012. Early in the millennium, foster care numbers decreased despite an increase in maltreatment reports, as child welfare offered families more preventive services and alternative placement with relatives or nonrelative caregivers ( kinship care ) as an alternative to court-ordered removal. The more recent increase in numbers appears to be related to the opioid epidemic. Over the last 15 years, reunification rates have stabilized while adoption of children from foster care has increased. Nationally, approximately 45% of children live with a nonrelative foster parent, 30% of children are in placement with a relative who is a certified foster parent, and just under 15% are in congregate (group) care .

Approximately 33% of children in foster care in the United States are younger than 5 yr, and 34% are older than 12 yr. Most children are white (41%); 24% are black, 21% are Hispanic of any race, and 7% are identified as ≥2 races. As foster care numbers declined by 25% beginning in 1999, the reduction in African American children was even greater as child welfare made efforts to reduce the disparities in investigation and removal. The average length of stay in foster care continues to decline (median in 2015, 20.4 mo), with a significant drop in the number who spend ≥2 yr from 31% in 2011 to 26% in 2015. Only approximately half of children achieve reunification, while 22% (53,000) are adopted and 6% reside with relatives. Among remaining children, 9% (20, 800) emancipate between ages 18 and 21 yr, 9% enter into long-term state guardianship, <1% run away, and 2% transfer to other institutions. There were 336 deaths reported in foster care in fiscal year 2015.

Only 4% of children reside in a preadoptive home, although they represent 12% of children awaiting adoption; 52% of children awaiting adoption reside with a foster parent who is a relative. The average number of placements a child experiences in foster care is not included in Adoption and Foster Care Analysis and Reporting System (AFCARS) , but important predictors of an increased number of different placements include severe behavioral and developmental problems, larger sibling group size, and longer time spent in foster care. Within 12 mo, almost all emancipated youth have at least 1 homeless night. Within a decade, less than half have achieved a high school degree, most are living in poverty, and many have psychiatric disorders, including posttraumatic stress disorder and depression.

Legislation in the United States

In the United States the Adoption and Safe Families Act (P.L. 105-89) requires that a permanency plan be made for each child no later than 12 mo after entry into foster care, and that a petition to terminate parental rights typically be filed when a child has been in foster care for at least 15 of the previous 22 mo. The Fostering Connections and Promoting Adoptions Act of 2009 (P.L. 110-351) focused on incentives for guardianship and adoption, supports for the young adults at the age of emancipation, and rights of Native American children to care within their tribe. This act also contained a clause requiring states to develop and coordinate healthcare systems for children in foster care in collaboration with Medicaid and pediatricians. In 2018 the Family First Prevention Services Act was signed into law. This legislation emphasizes providing evidence-based mental health and substance abuse services for families whose children are at imminent risk of entering foster care.

Early Childhood Trauma Leads to Poor Health Outcomes

Children in foster care have high rates of early childhood trauma and adversity. More than 60% are placed for neglect, 13% for physical abuse, and 5% are abandoned. Parental substance abuse is a factor in 32% of removals, and parent alcohol abuse in 6%. Violence in the home is common, with >80% having experienced domestic and/or community violence, but domestic violence is not included in the AFCARS reporting system as a reason for removal. Parental mental illness is also not reported as a reason for removal in AFCARS, but the literature indicates that birth parents have high rates of mental illness, criminal justice system involvement, substance abuse, unemployment, and cognitive impairment. Many children, particularly infants entering care, 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 may compound prior trauma experiences, although some children experience relief at removal from a chaotic, abusive, or dangerous home. Most children miss their family, worry about their parents and siblings, and long for reunification. Separation, loss and grief, unpredictable contact with birth parents, placement changes, the process of terminating parental rights, and the sheer uncertainty of foster care may further erode a child's well-being.

Childhood trauma is correlated with poor developmental, behavioral, and health outcomes. Early trauma and chronic stress adversely affect the neurobiology of the developing brain, especially those areas involved in attention, emotional regulation, memory, executive function, and cognition. As a result, shortened attention span, hyperactivity, poorer cognitive function, aggression, and memory issues are problems encountered frequently among children in foster care. However, evidence shows that specific interventions, such as specially trained foster parents for children or youth and mentoring for adolescents in foster care, can improve outcomes, although replication and dissemination of these evidence-based interventions are limited.

Health Issues

Experiencing multiple childhood adversities and receiving fragmented and inadequate health services before placement into foster care mean that children enter foster care with a high prevalence of chronic medical, mental health, developmental, dental, and educational problems ( Table 9.1 ). Thus they are defined as children with special health care needs (CSHCN). The greatest single healthcare need of this population is for high-quality, evidence-based trauma-informed mental health services to address the impacts of prior and ongoing trauma, loss, and unpredictability. In addition, children in foster care have higher rates of asthma, growth failure, obesity, vertically transmitted infections, and neurologic conditions than the general pediatric population. Adolescents need access to reproductive health and substance abuse services. Up to 60% of children <5 yr old have a developmental delay in at least 1 domain and >40% of school-age children qualify for special education services. Unfortunately, educational difficulties persist despite improvements in school attendance and performance after placement in foster care. Each placement change that is accompanied by a change in school sets children back academically by about 4 mo. Federal legislation requires child welfare to maintain children in their school of origin when possible, even if child welfare has to provide transportation to ensure this.