Key points

The term “foster care” has many connotations: crisis situations, endangered children, families unable to carry out parental responsibilities due to substance dependency, poverty, death, or abandonment. For this article, a working definition includes children in the custody of the following:

• •
  

  A county or state welfare system

  
  
• •
  

  A tribal court

  
  
• •
  

  Children who may live in a foster home, group home, kinship care, or residential treatment center

  
  
• •
  

  Children who will return home

  
  
• •
  

  Those for whom a permanent plan will be made

Foster care in the United States

From the English Poor Laws in the sixteenth century, it was common for poor children and adults to be indentured into service. Unlike slavery, this had a term, usually 7 years, after which time the indentured servant was free of the master who was providing board and keep for labor. Children were usually placed because they were orphans, not because of abuse or neglect, which was considered acceptable. The first foster “system” is considered the Children’s Aid Society in New York in 1853. The founder, Charles Loring Brace, conceived a unique solution to the thousands of orphan children on the streets of New York: putting them on “orphan trains” and sending them to farms. The results varied from loving homes to cruel treatment, but it gave the children placement. Societies were formed to protect children and then the supervision came under governmental auspices. In the twentieth century, the movement was from orphanages to foster care and, more recently, kinship care. In the 1960s, with the recognition of the prevalence of child abuse, laws were enacted in all states to mandate the reporting of child abuse and neglect. In 1974, the Child Abuse Prevention and Treatment Act, which provided funding to states, was passed by Congress. I993, the Family Preservation and Family Support Program (P.L.103-66), provided funding to states to help children either be returned to families or placed for adoption. The days of orphanages were becoming history. In 1997, the law was reauthorized and the law stressed time-limited reunification efforts and promoted adoption in an effort children would not linger in foster care.

Children enter the foster care system for many reasons: abuse, neglect, abandonment, or parental inability to care for them. Being in the system and separating them from their family/caregivers can accentuate the stress they experience.

Foster care in the United States

From the English Poor Laws in the sixteenth century, it was common for poor children and adults to be indentured into service. Unlike slavery, this had a term, usually 7 years, after which time the indentured servant was free of the master who was providing board and keep for labor. Children were usually placed because they were orphans, not because of abuse or neglect, which was considered acceptable. The first foster “system” is considered the Children’s Aid Society in New York in 1853. The founder, Charles Loring Brace, conceived a unique solution to the thousands of orphan children on the streets of New York: putting them on “orphan trains” and sending them to farms. The results varied from loving homes to cruel treatment, but it gave the children placement. Societies were formed to protect children and then the supervision came under governmental auspices. In the twentieth century, the movement was from orphanages to foster care and, more recently, kinship care. In the 1960s, with the recognition of the prevalence of child abuse, laws were enacted in all states to mandate the reporting of child abuse and neglect. In 1974, the Child Abuse Prevention and Treatment Act, which provided funding to states, was passed by Congress. I993, the Family Preservation and Family Support Program (P.L.103-66), provided funding to states to help children either be returned to families or placed for adoption. The days of orphanages were becoming history. In 1997, the law was reauthorized and the law stressed time-limited reunification efforts and promoted adoption in an effort children would not linger in foster care.

Children enter the foster care system for many reasons: abuse, neglect, abandonment, or parental inability to care for them. Being in the system and separating them from their family/caregivers can accentuate the stress they experience.

The numbers

There has been a marked decline in children entering the foster care system over the past decade, with black children in care declining 47.1% between 2002 and 2012. Blacks represent 12% of the US population, but black children represent almost one-quarter of all children in foster care.

The number of children in foster care varies; it is annually approximately 400,000, down from 524,000 in 2002 ( Box 1 , Tables 1 and 2 ).

The pediatrician’s role

The role of the pediatrician is to advocate for the child, not only in matters of physical health but also in mental health, educational, and social settings. Although medical providers educate parents and serve as their resource, we must also help the family, both birth parents and foster parents, navigate the health and welfare mazes they face; this is even more important when dealing with foster children. It is the responsibility of the pediatrician to assist the foster parent in understanding the child’s behaviors, where they may have originated, and how to work with the child to overcome negative behaviors.

The child entering the foster care system

Most children in the foster care system are eligible for Medicaid or a state child health plan. It is incumbent on health care providers, in cooperation with social service agencies, to ensure that children are enrolled in a medical plan, either managed care or fee-for-service. Children in foster care represent a twofold Medicaid expenditure; they account for between 1% and 3% of children receiving Medicaid but between 4% and 8% of Medicaid expenditures.

When possible, children in the foster care system should continue to receive care at the same facility, if not from the same provider. This may be the only continuity in the child’s life while in foster care. The health provider serves as a repository of the child’s health information as well as history of the child’s development and behavior. In an ideal world, the child would continue with the same provider who has cared for the child since birth. Unfortunately, children who enter the system may not have an established relationship with a provider or clinic.

In the Textbook of Pediatric Care , Szilagyi and Jee provide comprehensive guidelines for children entering foster or kinship care as follows:

Health screen within 72 hours of placement to assess and document the following:

• •
  

  Symptoms or signs of child abuse and neglect, with referral as needed

  
  
• •
  

  Growth parameters

  
  
• •
  

  Symptoms or signs of acute illness

  
  
• •
  

  Symptoms or signs of chronic illness

  
  
• •
  

  Developmental screening results and referral for evaluation

  
  
• •
  

  Behavioral and mental health screening results and referral for evaluation

  
  
• •
  

  Appropriate referral for emergent health issues or sexual abuse evaluation

  
  
• •
  

  Appropriate treatment of identified issues

  
  
• •
  

  Health education of foster or kinship caregiver

Health information gathering: an ongoing process that recognizes the importance of knowing the birth history, including maternal drug and alcohol use, prenatal care, and birth events, as well as prematurity and hospitalization.

Comprehensive health evaluation within 30 days of placement to

• •
  

  Review all available health history

  
  
• •
  

  Address health concerns

  
  
• •
  

  Assess adjustment to foster or kinship care, child care, school, and visitation

  
  
• •
  

  Address behavior concerns and daily schedule

  
  
• •
  

  Assess growth parameters

  
  
• •
  

  Perform a mental health evaluation or review evaluation or make referral

  
  
• •
  

  Perform a complete physical examination

  
  
• •
  

  Screen for signs and symptoms of child abuse and neglect

  
  
• •
  

  Perform all recommended routine screening tests per American Academy of Pediatrics guidelines for age and tests for at-risk children including hearing, vision, lead, complete blood count with differential, sexually transmitted diseases, hepatitis B and C

  
  
• •
  

  Review and administer needed immunizations

  
  
• •
  

  Provide age-appropriate anticipatory guidance with emphasis on transition issues

  
  
• •
  

  Provide appropriate or indicated treatment and referrals, including vision, hearing, and dental

  
  
• •
  

  Provide communication in writing of health plan to foster care agency

Follow-up admission assessment within 90 days of placement to

• •
  

  Review all the available history, assessments, and plans

  
  
• •
  

  Address interval concerns

  
  
• •
  

  Document growth parameters

  
  
• •
  

  Assess child and foster parent(s)’ concerns for adjustment

  
  
• •
  

  Screen for emerging signs of child abuse and neglect that may not have been observed earlier

  
  
• •
  

  Perform focused physical examination for any previously identified issues, including growth parameters, failure to thrive, or obesity

  
  
• •
  

  Review applicable school information, including the need for individual education plans (IEP)

  
  
• •
  

  Ensure that all referrals and recommended treatments are in progress or completed

Although the American Academy of Pediatrics’ schedule for pediatric preventive care can be followed if the child has had regular care, Szilagyi and Jee propose the following modified periodic preventive care schedule:

• •
  

  Children younger than 6 months should be seen monthly if considered high risk: developmental, growth, prematurity, prenatal drug/alcohol exposure

  
  
• •
  

  Children age 12 to 24 months should been seen every 3 months

  
  
• •
  

  Children between 2 and 21 years should be seen every 6 months

It is possible to allow a longer spacing if the child has been in the foster home a length of time for which the foster parent feels comfortable with any identified issues. It is important to be cognizant of the time demands on the foster family.

Approximately 70% of children in foster placement will return to the birth parents or relatives and thus it is desirable to allow birth families to participate in the initial screening whenever possible.