Journal Issue: Children, Families, and Foster Care Volume 14 Number 1 Winter 2004
Addressing the Needs of Children in Foster Care
Without question, preventing abuse, neglect, and entry into the foster care system is the best way to promote healthy child development. It is also true that foster care is a necessary lifeline that undoubtedly saves thousands of maltreated children each year. Nevertheless, placing children into state custody is an extremely invasive governmental intervention into family life and, as such, the government bears a special responsibility for children placed in state care. When the state assumes custody of a child, in effect the government is stating that it can do a better job of protecting and providing for this child than his or her birth parents can. When children are placed in foster care only to suffer additional harm, it undermines the rationale for government intervention and is an egregious violation of the public trust. For this reason, as Badeau writes in this journal issue, the first principle of the child welfare system should be to do no harm. The lives of children and families should be enhanced, not diminished, by the foster care experience.
This point is particularly significant given the vulnerable status and differing developmental needs of children who come into foster care. To uphold the government's responsibility to children in foster care, addressing children's needs must begin at entry with initial health screening and continue with regular assessments throughout a child's time in care. Case plans must be designed with a child's individual needs in mind so that services and supports are age-appropriate. In addition, child welfare agencies must incorporate cultural sensitivity into all aspects of practice to better serve the growing number of children of color in foster care.
Assessing Developmental and Health Care Needs
Most children who enter foster care have already been exposed to conditions that undermine their chances for healthy development. Most have grown up in poverty and have been maltreated—conditions associated with delayed development and, in the case of maltreatment, problems with behavior regulation, emotional disorders, and even compromised brain development.22 Once in foster care, the foster care experience itself can either exacerbate or ameliorate a child's problems Children in foster care are more likely to have behavioral and emotional problems compared to children who live in “high-risk”23parent care, and are at much higher risk of poor educational outcomes. One study found that a substantial number of children in the child welfare system had low levels of school engagement and were less likely to be involved in extracurricular activities.24
Children in foster care also have more physical and mental health problems than children growing up in other settings. Although children in foster care are more likely to have access to health insurance and receive needed health care compared to children in high-risk parent care, they often receive spotty or inconsistent care and suffer from a lack of continuity in health care.25 For example, a report by the U.S. General Accounting Office (GAO) found that 12% of children in care had not received routine health care, 34% had not received any immunizations, only 10% received services to address developmental delays, and even though three-quarters of the children were at high risk of exposure to HIV, fewer than 10% had been tested.26
Placement instability is one factor that negatively impacts continuity of care for children in foster care, as it is often difficult to track what services children have received when they move from placement to placement. Limited coordination and information sharing between the multiple service agencies that serve children in care also contributes to the problem.
In 2000 and 2002, the American Academy of Pediatrics issued guidelines on meeting the developmental and heath care needs of children in foster care. The guidelines recommend the following:
- Children should receive a health evaluation shortly after, if not before, entering foster care to identify any immediate medical needs;
- Children should receive a thorough pediatric assessment within 30 days of entry;
- Children should be assigned a consistent source of medical care (referred to as a “permanent medical home”) to ensure continuity of care;
- Children should receive ongoing developmental, educational, and emotional assessments.
Child welfare agencies should adopt these guidelines as a starting point for ensuring that children in foster care receive the health and educational supports they need.
RECOMMENDATION: Health Assessments
Child welfare agencies should ensure that all children in foster care receive health screenings at entry, receive comprehensive pediatric assessments within 30 days of placement, are assigned to a permanent “medical home,” and receive ongoing assessments and related treatment.
Monitoring Developmental Progress
For more than 20 years, child welfare scholars have called for monitoring the developmental progress and educational performance of children in foster care.27 The U.S. Children's Bureau has consistently emphasized that safety, permanence, and child well-being are the primary goals of the child welfare system. Yet, as Jones Harden discusses in her article in this journal issue, historically the system has focused on child protection, placement, and permanence, and has not fully addressed child functioning and healthy development, even though research demonstrates that these goals are closely intertwined.
The failure to focus on healthy development is due, in part, to the lack of well-being indicators for children in foster care. For example, CFSR reviewers are instructed to evaluate any available data on the well-being of children in foster care, but in most states, this information is contained in narrative form within individual case files. Few states have incorporated evaluative measures into administrative databases. The absence of standard indicators may also reflect the inherent difficulty of measuring child well-being and the reluctance of child welfare agencies to have their performance evaluated based on indicators that are affected by factors outside their control, such as the quality of schools and health care services.
Without standardized data, there is no base for the development of national standards to monitor child well-being. More could be done to support greater standardization to better monitor the healthy development of children while they are in state care. 28For example, with the CFSRs, the federal government has taken an initial step toward assessing how well states are promoting child well-being, but further steps are needed to ensure that child well-being indicators are incorporated into state database systems. For the past 10 years, the federal government has made matching funds available to states for the development of Statewide Automated Child Welfare Information System (SACWIS).29Currently, 47 states are in the process of implementing SACWIS.30 Now is an opportune time to ensure that child well-being measures are incorporated into these systems.
In addition, the Department of Health and Human Services (DHHS) should examine ways of providing better guidance and technical assistance to states to ensure the quality, accuracy, and completeness of data on child well-being. Some states have found that DHHS assistance in developing SACWIS has focused too narrowly on the quantitative measures currently included in the CFSRs. DHHS should encourage and support state efforts to incorporate child well-being indicators into their statewide systems. DHHS could look to various local programs as potential models for assessing child functioning, school performance, health status, and access to needed services. In San Diego, California, for example, a computerized health and education passport system allows agencies to monitor the well-being of children in foster care and determine whether they are receiving needed health, education, and counseling services.31
RECOMMENDATION: Measures of Well-Being
States should quantitatively measure how well the health and educational needs of children in foster care are being met and include these measures in their administrative data systems.
Providing Age-Appropriate Care
Children's developmental needs change significantly as they progress through childhood. Appropriate service plans for preschoolers are inappropriate for teenagers. Yet far too often, foster care services are not sensitive to children's differing developmental needs. Very young children and adolescents, in particular, face unique challenges and may require concerted attention to ensure that their developmental needs are met. Providing families with the necessary training and tools to meet a child's developmental needs, ensuring greater access to existing programs, and devising more creative ways of utilizing existing funding streams can result in better-tailored services and better outcomes for these two groups.
Infants and Toddlers
The foundation for healthy child development begins at birth, yet for some children, these early years are marred by maltreatment. Infants and toddlers are at much higher risk than older children for abuse and neglect and for entry into foster care. In 2001, nearly one-third of maltreated children were under the age of 3 and 40% of all child fatalities due to child abuse were infants under age 1.32Over the past 10 years, the number of infants and toddlers coming into foster care has increased by 110%.33 Approximately 1 in 5 of the children entering foster care for the first time are infants under age 1.34In urban areas, 1 in 20 infants younger than 3 months old enters foster care. Moreover, the very youngest children in foster care stay in care the longest time.35
These statistics are particularly worrisome given the developmental vulnerabilities of infants and toddlers. The fragility of children in foster care in the zero-to-three age group has been demonstrated in numerous studies.36 More than 40% of infants who enter foster care are born premature or low birth weight, and more than half of these babies experience developmental delays.37Children who experience abuse and neglect during this stage of development are more likely to experience abnormalities in brain development that may have long-term effects.38 Young maltreated children are also at greater risk of developing behavioral disorders, which can have a significant bearing on their social functioning later in life.
Special efforts must be made to ensure that these very vulnerable children grow up in healthy and nurturing environments. Foster parents of infants and toddlers should receive training on the special needs of young children and be informed of the supports available to them. A number of federal programs, if used creatively, could provide such training. For example, in addition to being eligible for monies from ASFA, Temporary Assistance for Needy Families (TANF), and Medicaid, young children with disabilities and their caregivers are entitled to receive such services as parent training, home visits, and respite care through the Early Intervention Program for Infants and Toddlers with Disabilities (Part C of the Individuals with Disabilities Education Act). These monies and services could be used to provide families caring for infants and toddlers with training on the vulnerabilities of very young children in foster care and on developmentally appropriate parenting of infants and toddlers.
Research on early-childhood programs demonstrates that they greatly improve educational, behavioral, and health outcomes for disadvantaged children.39 More promising, a recent study suggests that participation in certain types of early-childhood education programs can be especially beneficial for children at risk for abuse or neglect. A longitudinal study of the Chicago School District's Child-Parent Centers found that children in the program had a 52% lower rate of maltreatment compared to children who had participated in other early-education programs in the Chicago area.40 Children from high-poverty neighborhoods who attended the program experienced even greater reductions in child abuse and neglect than children in lower-poverty neighborhoods.41However, the Chicago program is somewhat unique among preschool programs. It is based on heavy parental involvement, relies on preschool providers with college degrees, and its participating families may not be representative of typical low-income families. Thus, the positive effects of this program may not be generalizable.42However, these findings do suggest that certain childhood education programs may help prevent maltreatment and improve developmental outcomes for children at risk.
Adolescence is a critical stage in child development. During these years, children begin to discover who they are, their place in the larger society, and their own empowerment. Special efforts are needed to encourage and promote the healthy development of this age group. Children between the ages of 11 and 18 constitute almost half (47%) of the foster care population. Approximately 17% are over age 16.43 These children need help in establishing healthy connections with other youth and caring adults, and in acquiring educational and life-skills training that can assist them in the transition to adulthood.
Older children in foster care face unique challenges. Children who enter foster care after age 12 are significantly less likely to exit to a permanent home than are all other children in foster care, including children with diagnosed special needs,44 and they are much more likely to simply age out of the system (to leave the system when they reach adulthood). Older children are less likely to live in a foster family and more likely to live in congregate care such as a group home.45However, the group home experience can be difficult for older youth. Like their younger counterparts, older youth crave the stability and nurturance a family environment can provide. They may perceive placement in a group home as a form of punishment.46
Many foster youth demonstrate remarkable resilience and transition out of the system to become healthy and productive adults. However, studies of youth who have left foster care indicate that they are more likely to become teen parents, engage in substance abuse, have lower levels of educational attainment, experience homelessness, and be involved with the criminal justice system compared to youth in the general population.47
Research suggests, however, that a number of steps can be taken to improve the experience of older children while they are in the foster care system and improve their outcomes as adults.48 First, it is important to develop individualized permanency plans that address a youth's unique needs. Children who enter care later in childhood face a different set of challenges than those who enter at a younger age, and case plans should acknowledge these differences. Second, it is important to include youth in the decision making regarding their case. Giving youth a voice in their care helps them to develop a sense of their future and can be empowering, as Massinga and Pecora note in their article in this journal issue. Third, it is important to explore a broad array of permanency options and possibilities for connectedness to improve the foster care experience of older youth. The need for a family does not end when a child enters the teen years. However, caseworkers need to think creatively to connect older youth to supportive family ties. For example, older youth often have a longer history with and clearer memory of their birth families. For that reason, relatives, siblings, and even close family friends can play an important role in creating a healthy social network for these teens. Other positive adult mentors can also be vital sources of social support for older children.
As Perez discusses in his commentary in this journal issue, few youth are prepared for full independence at age 18, and most continue to rely on family supports well into their twenties. Because older youth in foster care are less likely to have such family supports, it is important to provide them with independent-living-skills and life-skills training to help them in their transition to adulthood.
In the Foster Care Independence Act of 1999, Congress appropriated $140 million per year to support transitional services and extended eligibility for transition assistance to former foster children to age 21.49 To date, states are not fully accessing these funds or using them as effectively or creatively as they could.50 Innovative programs provide a creative means of assisting youth in the transition to adulthood. Examples of such programs include money management training and Individual Development and Education Accounts, which provide youth with incentive pay for accomplishments and teach them how to manage their money. Additionally, as discussed in the article by Massinga and Pecora, with the creative use of available federal funding streams, former foster youth may be able to cover most of the costs of attending a public university.
In sum, both very young and older children in foster care face unique challenges. The early years of childhood are a particularly vulnerable period developmentally, yet infants and toddlers are frequently victims of maltreatment, and their numbers in foster care have more than doubled in the last decade. Older children in foster care have their own specific developmental needs that must be met while in care, and they often face the additional challenge of aging out of the system without connections to a permanent family. However, more can be done to leverage existing resources to meet the needs of these children.
RECOMMENDATION: Specialized Services
States should use existing programs to provide specialized services for children of different ages in foster care, such as providing very young children with greater access to early-childhood preschool programs, and providing older children with educational and transitional supports until age 21.
Providing Culturally Competent Care for Children of Color
Since the 1960s, children of color51have been disproportionately represented in the child welfare system. Dramatic demographic shifts over the last two decades have also resulted in a greater number of children from diverse backgrounds entering the child welfare system. The long standing problem of racial disproportionality and the growing diversity of children in foster care require that the child welfare system make concerted efforts to ensure that all children are treated fairly and receive culturally competent care.
Children of color represent 33% of the children under age 18 in the United States, but 55% of the children in foster care.52Although African-American and American- Indian children are overrepresented, Latino and Asian or Pacific Islander children are underrepresented in foster care based on their numbers in the general population. Nationally, African-American children are represented in foster care at nearly three times their numbers in the population, and in some states this ratio can be as high as five times the population rate.53 American-Indian children are represented in foster care at nearly double their rate in the general population. According to the official data, Latino children are slightly underrepresented in child welfare based on their numbers in the population, but the number of Latino children in foster care has nearly doubled over the last decade.54The disproportionate representation of some groups of children of color in foster care is particularly disturbing given that research demonstrates that families of color are not more likely to abuse or neglect their children than white families of similar socioeconomic circumstances.55
It appears that poverty and poverty-related factors, high rates of single parenthood, structural inequities, and racial discrimination contribute to the disproportionate representation of children of color in foster care. African-American, Latino, and American-Indian children are much more likely to live in poor families, and poverty contributes to disproportionality both directly and indirectly. Although most poor families do not abuse their children, poor children are more likely to enter the foster care system, in part because poverty is associated with a number of life challenges, such as economic instability and high-stress living environments, which increase the likelihood of involvement with the child welfare system. Poor families are also more likely to have contact with individuals who are mandated by law to report child maltreatment, so questionable parenting practices are more likely to be discovered.56
Family structure may also contribute to disproportionality. Some evidence suggests that children of color are more likely to come from single-parent households and households where a parent or child is disabled—types of households that are also disproportionately represented in the child welfare system.57
Finally, the legacy of racial discrimination and its lingering manifestation in the form of institutional and social bias cannot be discounted; as such bias can lead to differential treatment. For example, one study found that although the prevalence of positive prenatal drug tests occurred at roughly the same rate for white and African-American women (15.4% versus 14.1%), African-American women were 10 times more likely to be reported to health authorities after delivery for substance abuse during pregnancy.58
The growing diversity of the child welfare population and the problem of racial disproportionality have implications for both service provision and civil rights. Children of color often receive differential treatment at critical junctures in the child welfare system. As Stukes Chipungu and Bent-Goodley note in their article in this journal issue, “Children of color receive fewer familial visits, fewer contacts with caseworkers, fewer written case plans, and fewer developmental or psychological assessments, and they tend to remain in foster care placement longer.” In addition, families of children of color have access to fewer services. For example, as Stukes Chipungu and Bent-Goodley report, even though substance-abuse rates are high among African-American families involved in foster care, community- based substance-abuse treatment frequently is not available or accessible to these families. Despite evidence that children of color receive differential treatment in the foster care system, remarkably little research has examined why this is so. Additional research on why children of color receive fewer services and less support compared to white children is needed to better understand the factors that lead to differential treatment and to eliminate barriers to providing appropriate and equitable care.
Efforts must also be made to address the unique developmental needs of children of color in foster care. Racial identity formation and finding one's place in a society that often categorizes and discriminates based on race are critical to healthy child development. Celebrating different cultures is a valuable practice, but cultural competency encompasses a range of attitudes, perspectives, and practices that prepare children of color to live within their culture of origin as well as in the larger society.
For some children of color, language barriers may pose additional difficulties. As Suleiman Gonzalez notes in her commentary in this journal issue, language access is both a cultural concern and a civil rights issue. Children from families with limited English proficiency are frequently placed with English-only families. This can create significant cultural confusion for the child during placement and undermine family reunification efforts should the child lose the ability to speak and understand the parents' native language. Moreover, as Suleiman Gonzalez notes, language difficulties that result in differential treatment for families with limited English proficiency represent a violation of their civil right to equality under the law.
To identify and provide appropriate services for children of color in foster care, child welfare agencies must embrace cultural competency as a central element of their mission and ensure that their organizational polices, practices, and procedures reflect sensitivity to the diversity of cultures they serve and to the ways in which individual families express their cultural heritage. Child welfare agencies need to take specific measures to infuse cultural competency throughout the child welfare system to better address the needs of children of color.
RECOMMENDATION: Cultural Competency
Child welfare agencies should enhance their cultural competency by recruiting bilingual and culturally proficient workers and foster families, ensuring that workers are sensitive to cultural differences, and incorporating assessments of cultural competency skills into worker performance evaluations.