Key points

Introduction: Foster care and trauma

Annually, about one quarter of a million children are removed from their families and placed in foster care when the child’s health and safety are deemed to be at imminent risk because of maltreatment. Removal of children from their family of origin and admission to foster care is and should be a weighty decision. Foster care is intended to be a temporary, healing refuge for children and families. But, because of the stressors that precipitate removal, the uncertainty, upheaval, and losses associated with placement, and the physiologic responses to these traumas, children in foster care often have a significant health burden. These effects are seen in children placed in various foster settings, with unrelated caregivers or with kin. The pediatrician needs to understand complex childhood trauma and how it affects children and families to provide care that promotes healing and improves outcomes.

Introduction: Foster care and trauma

Annually, about one quarter of a million children are removed from their families and placed in foster care when the child’s health and safety are deemed to be at imminent risk because of maltreatment. Removal of children from their family of origin and admission to foster care is and should be a weighty decision. Foster care is intended to be a temporary, healing refuge for children and families. But, because of the stressors that precipitate removal, the uncertainty, upheaval, and losses associated with placement, and the physiologic responses to these traumas, children in foster care often have a significant health burden. These effects are seen in children placed in various foster settings, with unrelated caregivers or with kin. The pediatrician needs to understand complex childhood trauma and how it affects children and families to provide care that promotes healing and improves outcomes.

Extent of the problem: Overview of foster care

Almost all children entering foster care are placed involuntarily by court order, the vast majority for reasons of maltreatment (70%) in the form of neglect (approximately 70%), physical abuse, sexual abuse, emotional abuse, or abandonment. Neglect of basic nutritional, educational, or medical needs, or lack of supervision, is the most commonly cited reason for placement; child physical and sexual abuse have declined in the recent decades. Removal may occur urgently after a first-time report to child protective services, or, at the other extreme, after prolonged involvement with child welfare during which preventive strategies have been exhausted. The remaining 30% of admissions are predominantly teens placed by the courts because of their own behaviors or because parents are seeking mental health services, cannot manage their behaviors, or abandon them. However, careful interview with an adolescent often uncovers a history of maltreatment and adversity.

More than half of a million children spend at least some time in foster care annually. In the last decade, there has been an overall decline of 23% in the foster care population. The overall number of children in foster care on a single day (September 30) declined from 523,616 in 2002 to 399,546 in 2012. The average duration of stay has also decreased from 31.3 to 22.4 months. These shifts occurred as child welfare made efforts to preserve families by diverting them from investigation to in-home support services and by engaging extended families as resources for children who could not safely remain at home. Child welfare also focused on shortening the time to permanency, whether through reunification, kinship care, guardianship, or adoption. Interestingly, these declines occurred despite an increase in child abuse reports and the numbers of children in foster care who had experienced multiple forms of maltreatment and were diagnosed as emotionally disturbed.

Although many children (approximately 50%) cycle through foster care in weeks to months, approximately 10% to 20% remain in the system for years. In 2011, about 50% of children were in care for fewer than 12 months; 17% had been in care for more than 3 years. Approximately 50% of children and teens will experience more than 1 foster care placement, with approximately 25% having 3 or more placements. The largest determinant of duration of stay is the biological family’s level of cooperation with the individualized case plan for their family, although minority children, older children, children with severe behavioral and developmental disabilities, and children who are part of large sibling groups are almost twice as likely to remain in care longer.

The average age of a child in foster care in 2011 was 9.1 years. Most children live either in nonrelative foster homes or kinship homes. Kinship is often broadly defined not just as relatives by blood or marriage, but other adult caregivers who have an established relationship with the child, such as godparents or family friends. Four percent of children reside in preadoptive homes and 16% live in group home or residential care. The race-ethnicity of children in foster care has changed, although minorities remain overrepresented. In 2011, 26% were black/Non-Hispanic, 21% were Hispanic, and 6% were multiracial. Subsets of children in foster care with unique needs and challenges include the intellectually disabled, the severely mentally ill, pregnant or parenting teens, unaccompanied refugee minors, and those abandoned by their families because of the child’s mental health or behavioral issues, or because they are gay, lesbian, bisexual, or transgender. Unaccompanied refugee minors have unique trauma histories as they enter foster care from a variety of countries after surviving war, rape, injury, slave labor, trafficking, or the death of family members.

More than 60% of children exit foster care for reunification with parents or relatives; about 20% are adopted. The 9% who emancipate annually usually do so on their 18th birthday, although legislation including the Chaffee Independence Act of 1999 and Fostering Connections to Success and Increasing Adoptions Act of 2008 have expanded funding to states to allow teens who are in school or job training to remain in foster care until age 21. Overall, the outcomes of youth who emancipate are discouraging. Foster care alumni are likely to be underemployed, undereducated, overrepresented among the homeless, and suffer from significant mental health problems.

The outcomes for children who reunify or are adopted are even less clear. There is some literature indicating that children who are adopted or remain in long-term stable foster/kinship care fare better than children who return to parents. About 30% of children who are returned to their families reenter care within 1 year. Approximately 9% to 24% of adoptions disrupt (before finalization) or dissolve (after finalization). Failed adoptions are more common for adolescents, with the child’s behavior being the most frequently cited reason.

Etiology: Toxic stress and complex trauma

The National Child Traumatic Stress Network defines complex trauma as encompassing both a child’s exposure to multiple traumatic events and the broad, pervasive, and predictable impact this exposure has on the individual child. To develop normally, children need an environment in which a responsive, attuned parent or caregiver meets their needs for adequate care, attention, and protection. Children rely on their parents and caregivers to mediate and buffer the world, and life’s stressors. When stressors are overwhelming or when parents are unable to help children buffer them, significant adversities, especially in early childhood, can undermine the development of adaptive capacities and coping skills, emotional well-being, learning, and physical health.

We have long known that stress leads to a predictable cascade of neuroendocrine changes that enable the individual to deal with a threat, real or perceived. Shonkoff and Garner delineate 3 types of stress that children experience that impact the development of their brains: positive stress, which promotes and is necessary for healthy adaptation and development; tolerable stress, which children are able to manage with help by protective factors, such as an attuned parent; and toxic stress, which causes a chronic or frequent activation of the child’s physiologic stress response system and is not adequately buffered. Unlike positive or tolerable stress, toxic stress leads, through the excessive or prolonged activation of physiologic stress response systems, to alterations in gene translation, immune response, and neurodevelopment, resulting in predictable behavioral, learning, and health problems. Those areas of the brain involved in cognition, rational thought, emotional regulation, activity level, attention, impulse control, and executive function are particularly vulnerable, especially in the young child. In addition, although genetic predisposition plays some role in the stress response, early and prior experience can magnify the effect. Children in foster care have usually experienced chronic, recurrent, or multiple traumas within a chaotic family environment that lacks sufficient buffering and protection, placing them at high risk for complex trauma.

Poverty contributes significantly to complex trauma. Poverty is a pervasive underlying theme for families whose children enter foster care; the poverty extends beyond the financial to a poverty of social supports and parenting skills necessary to create the nurturing and predictable environment children need to thrive ( Box 1 ).

Sequelae of the problem: How trauma impacts the health of children in foster care

The interplay of toxic stress, physiologic response, and behavioral adaptations to stress impact the health of children in childhood and over the life course. In the 1990s, the Adverse Childhood Experience studies began to make the link between childhood toxic stress and poor adult health outcomes, including cardiovascular and pulmonary disease, cancer, asthma, autoimmune disease, and depression. Exposure to drugs in utero, insufficient prenatal care, prematurity, exposure to environmental toxins, and exposure to HIV, hepatitis, tuberculosis, and other communicable diseases, in addition to chronic neglect, physical, and sexual and emotional abuse, have previously been linked with poor health outcomes for children in foster care, both in the short term and into adulthood. Growing literature has begun to elucidate how toxic stress takes its toll. Immune response, as influenced by the neuroendocrine stress response, leads to biologic changes and adaptations that can acutely and chronically lead to poor health outcomes.