# 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.