52 - 31.19b Adoption and Foster Care

31.19b Adoption and Foster Care

children with autism spectrum disorders. J Dev Behav Pediatr. 2013;34(1):1–8. 31.19b Adoption and Foster Care According to the U.S. Department of Health and Human Services, 408,425 children and adolescents were in foster care in the United States in 2010. Most children entering foster care have experienced multiple traumatic events including neglect, or abuse, which are typically the precipitant for their removal from their biological parents. One study estimated that 26 percent of children in the United States will experience a traumatic event by the age of 4 years. Over the last decade, specifically between the years of 2000 to 2010, the number of evaluations for suspected child maltreatment has increased by 17 percent, according to another study. Foster care is intended to be temporary out-of-home care, provided by the welfare system, for children and adolescents whose immediate families are unable to care for them. Given the severity of the pathology of vulnerable parents; however, care is often needed for many months and years. In 1997, President Clinton signed the Adoption and Safe Families Act, a law designed to improve provisions for child safety, to decrease the length of time that a child remains in foster care without long-term planning, and to limit the amount of time in which a biological parent has to undergo rehabilitation to 12 months. An additional law was added to allocate federal funds for independent living assistance for adolescents and young adults aged 16 to 21 to assist them in transitioning to independent living. EPIDEMIOLOGY AND DEMOGRAPHICS OF FOSTER CARE The number of children entering foster care due to maltreatment has risen in the last decade by 19 percent. Of those children who entered foster care, there was an increase of 60 percent in the number who were identified as emotionally disturbed. In the United States, one of the most common scenarios of children being placed in foster care involves parental substance abuse, which leads to inability of the parent to care for their children. The National Center on Addiction and Substance Abuse of Columbia University reported that seven of ten abused or neglected children had parents with substance abuse. Furthermore, children in foster care were more often being raised by a single mother prior to placement compared to children in the community. Minority children are overrepresented in the foster care population. In a study utilizing birth records and child protective service (CPS), black children were more than twice as likely to be referred due to maltreatment, be substantiated as victims of maltreatment, and enter the foster care system before age 5 years, compared to white children. However, low socioeconomic black children had a lower rate of referral, substantiation, and placement in foster care than socioeconomically similar white children. Among Latinos, children of U.S.-born mothers were significantly more likely to have involvement with CPS, compared to Latino children of foreign-born mothers. However, after adjusting for socioeconomic factors, the relative risk of referral,

substantiation, and entry into the foster care system was significantly higher for all Latino children than for white children. Approximately 38 percent of children in the foster care system are African American, more than three times their representation in the general population. Whites make up approximately 48 percent, and Hispanics make up almost 15 percent of foster children; 55 to 69 percent are girls, and 83.4 percent enter foster care at a mean age of 3 years. Children placed in care as infants are more likely to stay in care. Those younger than 5 years of age currently comprise the fastest growing segment of the foster care population. Studies reveal that up to 62 percent of foster children had prenatal drug exposure. NEEDS OF FOSTER CARE CHILDREN Children entering foster care have enormous mental health needs; more than 80 percent of them have developmental, emotional, or behavioral problems. It is estimated that up to 70% of these children have diagnosable psychiatric disorders. In addition, according to one study, quality of life (QOL) is significantly poorer among children in the foster care system than children in the general community. Children and adolescents living in residential care rated their QOL as poorer than those living with foster families. Up to 50 percent of foster care children exhibit depressive symptoms, and self-reports of anxiety problems occur in about 36 percent. QOL is adversely affected by the presence of mental health problems, and those youth with greater mental health difficulties rated their QOL as poorer whether in residential facilities or foster placement. In a review of the literature, psychiatric disorders found with increased frequency in foster youth were attention-deficit/hyperactivity disorder (ADHD), posttraumatic stress disorder, conduct disorders, attachment disorders, substance abuse, depression, and eating disorders. In addition to high rates of psychiatric disorders, foster care youth are referred to pediatric clinics more frequently due to multiple health problems compared to community youth. Growth abnormalities (including failure to thrive), neurological abnormalities, neuromuscular disorders, language disorders, cognitive delays, and asthma are prevalent. Health care costs in foster care youth are six to ten times that of matched non–foster-care peers. Among children 0 to 5 years of age, approximately 25 percent are seriously emotionally damaged; attachment disorders are increasingly diagnosed. Foster care children use the full range of mental health services: outpatient, acute inpatient, day treatment, partial hospitalization, and residential treatment. Adolescents in foster care are at increased risk for substance abuse, teenage pregnancies, and sexually transmitted diseases, including human immunodeficiency virus (HIV). With public health care increasingly adopting a managed health care system, which is designed to limit care, grave concern exists that the provision and delivery of services to this medically and psychiatrically vulnerable population may be seriously compromised. KINSHIP CARE FOR FOSTER CHILDREN More states are recognizing kinship care as an alternative placement option and are

authorizing licensing and reimbursement to kinship caregivers who are generally female (mostly maternal grandmothers), of low income, of low education, and of minority status. Currently, nationwide, approximately 23 percent of African American children are in foster kinship care. It is unknown just how many children are in informal kinship care within the African American population, which has had a long cultural tradition of taking in children of family members who are unable to care for their offspring. The few studies available indicate that outcomes, although mixed, are somewhat more positive than for those children in nonkinship care. Children reportedly receive more positive regard from caregivers in kinship care, and a consistent outcome, when it works, is that it provides more stability than nonrelative foster care. Most foster children have consistently said that they would rather be with a family member than stay in the system. When foster children feel embraced by their families of origin, and the latter can provide appropriate nurturance and access to good therapeutic services, the foster children’s sense of identity and belonging is less disrupted. However, no demonstrable difference is seen in the need for mental health, medical, and special educational services for these children. THERAPEUTIC FOSTER CARE Therapeutic foster care (TFC) has emerged as a cost-effective alternative to the more restrictive residential treatment center (RTC). Therapeutic effectiveness is mixed. TFC is designed to provide nurturing family-based care with specialized treatment interventions from an interdisciplinary treatment team. Therapeutic foster parents are meant to be the agents of therapeutic change, functioning as extenders of the clinical treatment team. Because of the children’s special needs, therapeutic foster parents must have more extensive training than other foster parents, receive a higher reimbursement, and receive more intensive monitoring, supervision, and support from the foster care agency. Although the concept of TFC is promising, good outcome data do not show consistent success. Several models exist, but implementation that shows fidelity to empirically tested models is often spotty. Some models have proved too expensive and complicated to implement in the real-world setting. The concept of professional therapeutic parents, who are paid competitive full-time wages to care for special needs foster children, holds promise as an alternative to current prevailing practice. Clinical practice demonstrates that, when adequate and appropriate intensive in-home services with good case management is provided in a well-managed foster care setting, children can show significant gains. CULTURAL COMPETENCE Anna McPhatter defines cultural competence as the ability to use knowledge and cultural awareness to design psychosocial interventions that support and sustain healthy client– system functioning within a cultural context that is meaningful to the client. Because American society is still significantly encumbered by racial conflicts, some children have been denied placement with families of a different race, and have ended up in long-term

foster care rather than in a permanent adoption placement. The Association of Black Social Workers went on record as opposing transracial placement of African American children. In 1978, the Indian Child Welfare Act transferred to Tribal Courts the power to make placement decisions about Native American children to reverse the practice of placement in non–Native American homes. Adoption studies have shown that it is not inherently harmful for children to be cross-racially adopted. Congress has passed legislation, the Multiethnic Placement Act of 1994, facilitating transracial adoptions, while maintaining the language of cultural awareness in placement decisions. The need for cultural sensitivity, respect, and a capacity to facilitate a foster child’s cultural development and identity are well acknowledged. These issues must be addressed in training providers of foster care services. PSYCHOLOGICAL ISSUES IN FOSTER CARE CHILDREN Family risk factors including alcohol and drug abuse in parents, parental neglect and abuse, and cognitive or mental or physical health problems in parents, as well as low socioeconomic status and low social support, are strongly associated with a child being placed out of the home. Psychiatric and behavior problems in the child may also contribute to being placed out of the home. Among children who return home, 40 percent reenter the foster care system. These children struggle with issues of abandonment, neglect, rejection, and physical, emotional, and sexual maltreatment. The child’s age, home environment, and the specific reasons for going into placement affect the emotional issues that the child must handle. Early abandonment and neglect can lead to anaclitic depression. Attachment issues are prevalent in this young population, because there has been no opportunity to form secure attachments with consistent nurturing figures in early life. Foster children are often unprepared for separations, which can be abrupt and repeated in the current foster care climate. Early separation from the primary caretaker is considered a major trauma for a child and sets the stage for vulnerability to subsequent trauma. Those children who bounce from foster home to foster home have their capacity to form enduring emotional attachments compromised; trust becomes a lifelong challenge. Children who have experienced traumatic physical and sexual abuse often become mistrustful, hypervigilant, aggressive, impulsive, oppositional, and avoidant as they attempt to negotiate a world that they experience as threatening, hostile, and uncaring. When a child’s early developmental period is spent in a psychosocial environment of trauma, aggression, and lack of empathy from adults, the psychological seeds are sown for later violence against the self and others. A wide range of behavior problems is likely to emerge in foster care children given their early family experiences. A pervasive problem is one of dysregulation: dysregulation of behavior, emotions and affect, attention, and sleep. The empirical data on the neurobiology of maltreatment on the developing brain reveals that stress hormones play an important role in adaptation and coping, and that these capacities are compromised in varying degrees of severity in abused and neglected children. The data also show that, because of the developmental plasticity of the brain, appropriate early intervention can induce remediation and repair at the neurobiological level.

Nick, a 5-year-old, was placed in foster care because of maternal substance abuse and inability to take care of her child. When seen for a psychiatric evaluation, it was noted that all of his primary teeth were full of dental cavities. The foster mother was asked about dental care, and she responded that the dentist had said that he would wait until the teeth had fallen out, because they were his first set of teeth and did not require intervention. This response aroused suspicion that neglect in the foster family was exacerbating Nick’s hyperactive and aggressive behaviors. A neglect report was made and the investigation revealed that Nick was not only neglected, but was also being physically abused in that foster care placement. Subsequent to removal and placement with a nurturing and responsible foster family, Nick has shown considerable emotional stabilization, does well academically and socially, and is now being adopted by that family. (Adapted from case material Marilyn B. Benoit, M.D., Steven L. Nickman, M.D., and Alvin Rosenfeld, M.D.) FAMILY PRESERVATION Family preservation has come under increasing scrutiny in the last decade. Estimates on the percentage of children who are reportedly reunited vary from 66 to 90 percent. Philosophically, family reunification appears to be the right thing to do, yet approximately 40 percent of reunified children reenter out-of-home care. The field needs discriminating criteria that would identify psychosocial profiles of families that could best benefit from family preservation services. In 1996, the Child Welfare League of America (CWLA) acknowledged the failure of family preservation efforts and requested that child welfare policy makers rethink the current use of intensive family preservation. Recent research has validated poor outcomes with family preservation. Hopes are that the Adoption and Safe Families Act of 1997 will give child welfare agencies the opportunity to step back from the myopic view of family preservation and to consider the needs of the child as the major priority. The AACAP and the CWLA jointly launched a national effort to address the mental health needs of children in foster care. This effort is supported by a broad-based coalition of agencies that are all stakeholders in foster care. The coalition proposes that the foster care system be child focused, but inclusive of the biological and foster families in intervention planning on the child’s behalf if families are to be preserved. One case of a 7-year-old boy who was in foster care for 2 years is illustrative of why some family preservation efforts fail. When James was returned to his biological mother, she was in a new marriage with a new baby. Her husband was new to parenting. The family was financially strapped and lived under harsh conditions. James’ mother completed the required parenting course for resuming custody of her child, and seemed pleased to have him back with her; however, no supports were put in place to assist this young couple financially or with any family therapy,

psychoeducation, or case management interventions. Frequent and increasingly urgent calls to the child welfare family reunification services were made to seek respite and financial help, but this was not possible. The outcome for James was that he was reabused and had to reenter the foster care system. This outcome represents a failure of the system, but also translates into a debilitated family, with a profound sense of failure. (Adapted from case material from Marilyn B. Benoit, M.D., Steven L. Nickman, M.D., and Alvin Rosenfeld, M.D.) FOSTER CARE OUTCOMES AND RESEARCH INITIATIVES The overall quality of available outcome studies is poor. Some patterns, however, recur across studies. Several studies reveal that 15 to 39 percent of the homeless are foster care graduates, who are also overrepresented among adult substance abusers and clients in the criminal justice system. It is likely that the reasons that initially precipitated the child’s foster care placement contributed to the negative adult outcomes. Studies indicate that children entering care who have been victimized, who have substance-abusing parents or parents with major mental illness or high criminality, or both, and who come from homes with a high degree of domestic violence are at greater risk of having poor outcomes. Research on early maltreatment indicates that the influence of maltreatment on brain development can be profound over the life span. Developmental disabilities occur in more than 50 percent of the foster care population. Children returned to their families of origin typically have fared worse than those who have remained in long-term placement. Several studies report findings indicating that multiple placements and poor parental involvement consistently lead to negative outcomes. Federal mandate requires states to maintain a tracking system for children in foster care. New reporting systems, the Adoption and Foster Care Analysis and Reporting System (AFCARS) and the Statewide Automated Child Welfare Information System (SACWIS), are available nationwide. States are being monitored for compliance with their use, and continued federal funds are contingent on the implementation of these information systems. Because foster care placement is the result of psychosocial environmental failure, fixing the existing system requires more than good information systems. Integration of sound, theory-driven, child-focused, family-centered services, collaboratively funded by multiple governmental agencies, is essential. Through the use of longitudinal, research-based performance measures, reliable data are emerging. The National Institutes of Mental Health (NIMH) has funded some research focusing on foster care children and youth. The complexity of the impact of ever-changing psychosocial variables makes this type of research challenging. Despite that, it must be done if welfare dollars are to be spent doing the right thing for needy children and their families. In 2004, in a groundbreaking study, the Pew Commission on Children in Foster Care made sweeping recommendations to overhaul the system, stating that “children deserve more from our child welfare system.” HISTORY OF ADOPTION Adoption has existed in different forms throughout history. In ancient Babylonia, it provided for the transmission of property or artisan’s skills, whereas, in the Roman Empire, it was often used to elevate the status of an adult protégé. In some Pacific

islands, adoption of young children formed part of an exchange system between related clans. Concerns expressed by adopted persons about not knowing their roots are as ancient as they are contemporary. Euripides’ Ion contains a touching dialogue between a woman in search of the child she had given up years before and a young priest of Apollo, who does not know that he is the woman’s son and says that the only mother he knows is Apollo’s priestess. Historically, closed adoptions were common practice. That was done to ensure the sealed identities of birth and adoptive parents and was believed to be in the best interests of adopted children. That practice is now considered flawed; contemporary, although still controversial, thinking is that most adoptees should grow up knowing of their adoption status, as well as the identities of their birth parents. Currently, adoptees, as well as many birth parents and adoptive parents, increasingly have shared interests in legislation that affects the open or closed status of birth records and the placement of children in families. The phrase adoption triad has come to stand for these shared interests. Several other organizations represent each of these three groups, and those organizations often have divergent agendas. Since the 1980s, adoption practice has been profoundly affected by federal legislation. EPIDEMIOLOGY OF ADOPTION Estimates suggest that between 2.5 and 3.5 percent of children in the United States are adopted, with more than 2 percent adopted by nonrelatives, and about 1.5 percent in relative adoptions, which include stepparents. Foster care children who are adopted account for about 15 percent of all adopted children. Approximately 125,000 children are adopted each year, in a variety of scenarios. Infants may be relinquished by their biological parents at birth and adopted through private agencies. These adoptions are increasingly “open,” with some continued contact with biological parents. About 50,000 babies are adopted in this manner each year. Another 50,000 children are adopted through the child welfare system, and these children have often been exposed to multiple foster home placements before they are adopted. These adoptees range in age, with more than half of them being older than 6 years of age, and the majority of them having experienced significant early abuse or neglect. INTERNATIONAL ADOPTION International adoptions have been growing over the last two decades. Each year more than 20,000 children are adopted from overseas, and many of these are transracial adoptions. More than 17,000 children were adopted from Guatemala, for example, in the last two decades. In the Guatemalan adoptees, the mean age was 1.5 years and the children had previously resided in orphanages, foster homes, or mixed-care settings. Investigation of the health records of international adoptees who were evaluated in an international adoption specialty clinic in the U.S. revealed that younger children at the time of adoption have better growth, language development, cognitive skills, and competence in activities of daily living compared to children who were older at time of

adoption. Among children matched for age, gender, and time from adoption to evaluation, those who were previously living in foster care were observed to have higher cognitive scores and improved growth compared to children who had resided in orphanages. These findings support the priority of adoptive placement at younger ages and that foster care has benefits over orphanage care. EARLY CHILDHOOD VERSUS LATE ADOPTION Data suggest that earlier age adoption predicts better outcome than adoption in middle or late childhood. A recent prospective study examined factors related to successful outcome in public adoption of children ranging in age from 5 to 11 years of age. Prospective data were collected from domestic adoptions in the United Kingdom at the 1st year, and 6 years later on 108 adoptees who were placed primarily because of situations involving childhood abuse and neglect. Outcome was assessed by the disruption rate and measures of psychological adaptation. At the adolescent follow-up, 23 percent of the adoption placements had been disrupted, 49 percent were continuing with positive adaptations, and 28 percent were ongoing but with significant conflicts. Four factors contributed independently to the risk of disruptions: older age at placement, report of being singled out and rejected by siblings, time in care, and greater degree of behavioral problems. Given that almost half of the placements were ongoing, it is apparent that later childhood age of adoption can also be successful; assessment of the constellation of the adoptive families, and of the children’s behavioral problems, may determine the likelihood of positive outcome for school-aged child adoptees. BIRTH PARENTS: SEARCH AND REUNION The increasing trend toward open adoption allows the opportunity for adoptees to more easily search and successfully find their birth parents. Many adoptive parents choose open adoptions in the belief that they can experience a greater connection with the child if they have some relationship with the birth mother. Some adoptees want to develop an ongoing relationship with birth parents, but many who search are satisfied to meet birth parents without further correspondence. Outcomes of reunions with birth parents vary widely. In some cases, especially when the birth parents are well functioning and welcoming toward their child, the adoptee may experience a sense of relief and joy in knowing that their birth mother is no longer vulnerable. REFERENCES Brenner E, Freundlich M. Enhancing the safety of children in foster care and family support programs: Automated critical incident reporting. Child Welfare. 2006;85:611. Briggs-Gowan MJ, Ford JD, Fraleigh L, McCarthy K, Carter AS. Prevalence of exposure to potentially traumatic events in a healthy birth cohort of very young children in the northeastern United States. J Traum Stress. 2010;23:725–733. Conn AM, Szilagyi MA, Franke TM, Albertin CS, Blumkin AK, Szilagyi PG. Trends in child protection and out-of-home care. Pediatrics. 2013;132:712–719. Carnochan S, Moore M, Austin MJ. Achieving timely adoption. Journal of Evidence-Based Social Work. 2012;10:210–219.