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Foster Families

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Foster Care

Over 500,000 children in the U.S. currently reside in some form of foster care. Placements in foster care have dramatically increased over the past 10 years. 

Despite the increasing numbers, children in foster care and foster parents are mostly invisible in communities and often lack many needed supports and resources. In situations of abuse and neglect, children may be removed from their parents' home by a child welfare agency and placed in foster care

Other reasons for foster placement include severe behavioral problems in the child and/or a variety of parental problems, such as abandonment, illness (physical or emotional), incarceration, AIDS, alcohol / substance abuse and death.

African-American children make up approximately 2/3 of the foster care population and remain in care longer. 2 out of 3 children who enter foster care are reunited with their birth parents within 2 years. 

A significant number, however, can spend long periods of time in care awaiting adoption or other permanent arrangement.  Making decisions about the future for a child in foster care is called A permanency planning.

Options include:

  • returning the child to his/her birth parents

  • termination of parental rights (a formal legal procedure) to be followed, hopefully, by adoption

  • long-term care with foster parents or relatives 

Most states encourage efforts to provide the birth parents with support and needed services (e.g. mental health or drug/alcohol treatment, parent skills, training and assistance with child care &/or adequate housing) so their child can be returned to them. 

When parental rights have been terminated by the court, most states will try to place children with relatives (A kinship foster care or  A relative placement) which may lead to adoption by the relative. 

Being removed from their home and placed in foster care is a difficult and stressful experience for any child.  Many of these children have suffered some form of serious abuse or neglect. 

About 30% of children in foster care have severe emotional, behavioral, or developmental problems. Physical health problems are also common. 

Most children, however, show remarkable resiliency and determination to go on with their lives. Children in foster care often struggle with the following issues:

  • blaming themselves and feeling guilty about removal from their birth parents

  • wishing to return to birth parents even if they were abused by them

  • feeling unwanted if awaiting adoption for a long time

  • feeling helpless about multiple changes in foster parents over time

  • having mixed emotions about attaching to foster parents

  • feeling insecure and uncertain about their future

  • reluctantly acknowledging positive feelings for foster parents

Foster parents open their homes and hearts to children in need of temporary care, a task both rewarding and difficult. 

Unfortunately, there has been a decrease in the number of foster parents (non-relative) available to care for children over the past 10 years.  This results in larger numbers of children remaining in institutional settings. The number of relative caregivers (A kinship foster care), however, has increased.

Reimbursement rates for foster parents are lower in most states than the true costs of providing routine care for the child.  Important challenges for foster parents include:

  • recognizing the limits of their emotional attachment to the child

  • understanding mixed feelings toward the child's birth parents

  • recognizing their difficulties in letting the child return to birth parents

  • dealing with the complex needs (emotional, physical, etc.) of children in their care

  • working with sponsoring social agencies

  • finding needed support services in the community

  • dealing with the child's emotions and behavior following visits with birth parents

Children in foster care who have emotional or behavioral problems may be referred for a psychiatric evaluation.  Some child and adolescent psychiatrists provide consultation to Juvenile / Family Courts and child welfare agencies. 

Child and adolescent psychiatrists also provide comprehensive evaluations including diagnosis and the development of treatment plans. They also provide direct treatment (e.g. psychotherapy, family therapy, psychiatric medication) to a child. 

Children in foster care have special and complex needs which are best addressed by a coordinated team which usually includes the birth parents, foster parents, mental health professionals (including child and adolescent psychiatrists) and child welfare staff.

Source: AACAP Updated May 2005

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As stated above, some children in foster care come from a situation in which they were abused; some sexually abused. Read below about what happens when children are sexually abused to get more of an idea as to what these children are feeling, as well as what foster parents are faced with taking in sexually abused children.
Foster families taking in kids that have experienced abuse need to understand the ramification of taking care of a child that has been abused - they have additional special needs that aren't usually faced by children that come from a loving family.

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Child Sexual Abuse

Child sexual abuse has been reported up to 80,000 times a year, but the number of unreported instances is far greater, because the children are afraid to tell anyone what has happened and the legal procedure for validating an episode is difficult.

The problem should be identified, the abuse stopped and the child should receive professional help. The long-term emotional and psychological damage of sexual abuse can be devastating to the child.

Child sexual abuse can take place within the family, by a parent, step-parent, sibling or other relative; or outside the home, i.e., by a friend, neighbor, child care person, teacher, or stranger. When sexual abuse has occurred, a child can develop a variety of distressing feelings, thoughts and behaviors.

No child is psychologically prepared to cope with repeated sexual stimulation. Even a 2 or 3 year old, who can't know the sexual activity is wrong, will develop problems resulting from the inability to cope with the overstimulation.

The child of 5 or older who knows and cares for the abuser becomes trapped between affection or loyalty for the person and the sense that the sexual activities are terribly wrong. If the child tries to break away from the sexual relationship, the abuser may threaten the child with violence or loss of love.

When sexual abuse occurs within the family, the child may fear the anger, jealousy or shame of other family members, or be afraid the family will break up if the secret is told.

A child who is the victim of prolonged sexual abuse usually develops low self-esteem, a feeling of worthlessness and an abnormal or distorted view of sex. The child may become withdrawn and mistrustful of adults and can become suicidal.

Some children who have been sexually abused have difficulty relating to others except on sexual terms. Some sexually abused children become child abusers or prostitutes, or have other serious problems when they reach adulthood.

Often there are no obvious physical signs of child sexual abuse. Some signs can only be detected on physical exam by a physician.

Sexually abused children may develop the following:

  • unusual interest in or avoidance of all things of a sexual nature

  • sleep problems or nightmares

  • depression or withdrawal from friends or family

  • seductiveness

  • statements that their bodies are dirty or damaged, or fear that there's something wrong with them in the genital area

  • refusal to go to school

  • delinquency/conduct problems

  • secretiveness

  • aspects of sexual molestation in drawings, games, fantasies

  • unusual aggressiveness, or

  • suicidal behavior

Child sexual abusers can make the child extremely fearful of telling, and only when a special effort has helped the child to feel safe, can the child talk freely.

If a child says that he or she has been molested, parents should try to remain calm and reassure the child that what happened wasn't their fault. Parents should seek a medical examination and psychiatric consultation.

Parents can prevent or lessen the chance of sexual abuse by:

  • Telling children that if someone tries to touch your body and do things that make you feel funny, say NO to that person and tell me right away

  • Teaching children that respect doesn't mean blind obedience to adults and to authority, i.e., don't tell children,"Always do everything the teacher or baby-sitter tells you to do."

  • Encouraging professional prevention programs in the local school system

Sexually abused children and their families need immediate professional evaluation and treatment. Child and adolescent psychiatrists can help abused children regain a sense of self-esteem, cope with feelings of guilt about the abuse and begin the process of overcoming the trauma.

Such treatment can help reduce the risk that the child will develop serious problems as an adult.

Source: AACAP No. 9; Updated July 2004

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Responding To Child Sexual Abuse

When a child tells an adult that he or she has been sexually abused, the adult may feel uncomfortable and may not know what to say or do. The following guidelines should be used when responding to children who say they have been sexually abused:

What to Say
If a child even hints in a vague way that sexual abuse has occurred, encourage him or her to talk freely. Don't make judgmental comments.

  • Show that you understand and take seriously what the child is saying. Child and adolescent psychiatrists have found that children who are listened to and understood do much better than those who are not. The response to the disclosure of sexual abuse is critical to the child's ability to resolve and heal the trauma of sexual abuse.

  • Assure the child that they did the right thing in telling. A child who is close to the abuser may feel guilty about revealing the secret. The child may feel frightened if the abuser has threatened to harm the child or other family members as punishment for telling the secret.

  • Tell the child that he or she is not to blame for the sexual abuse. Most children in attempting to make sense out of the abuse will believe that somehow they caused it or may even view it as a form of punishment for imagined or real wrongdoings.

  • Finally, offer the child protection, and promise that you will promptly take steps to see that the abuse stops.

What to Do
Report any suspicion of child abuse. If the abuse is within the family, report it to the local Child Protection Agency. If the abuse is outside of the family, report it to the police or district attorney's office. Individuals reporting in good faith are immune from prosecution. The agency receiving the report will conduct an evaluation and will take action to protect the child.

Parents should consult with their pediatrician or family physician, who may refer them to a physician who specializes in evaluating and treating sexual abuse. The examining doctor will evaluate the child's condition and treat any physical problem related to the abuse, gather evidence to help protect the child, and reassure the child that he or she is all right.

Children who have been sexually abused should have an evaluation by a child and adolescent psychiatrist or other qualified mental health professional to find out how the sexual abuse has affected them, and to determine whether ongoing professional help is necessary for the child to deal with the trauma of the abuse. The child and adolescent psychiatrist can also provide support to other family members who may be upset by the abuse.

While most allegations of sexual abuse made by children are true, some false accusations may arise in custody disputes and in other situations. Occasionally, the court will ask a child and adolescent psychiatrist to help determine whether the child is telling the truth, or whether it will hurt the child to speak in court about the abuse.

When a child is asked as to testify, special considerations - such as videotaping, frequent breaks, exclusion of spectators, and the option not to look at the accused - make the experience much less stressful.

Adults, because of their maturity and knowledge, are always the ones to blame when they abuse children. The abused children should never be blamed.

When a child tells someone about sexual abuse, a supportive, caring response is the first step in getting help for the child and reestablishing their trust in adults.

Source: AACAP No. 28; Updated July 2004

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Short Term Problems for Abused & Neglected Children
  • fear and anxiety
  • sexualized behaviors
  • nightmares
  • social withdrawal or isolation
  • sleep problems
  • anger/acting out
  • somatic difficulties
  • school difficulties
  • Posttraumatic stress disorder (PTSD)
  • traumatic sexualization
  • betrayal
  • stigmatization
  • powerlessness
  • difficulty regulating emotional responses
  • interpersonal problems
  • effects on self-perception

Children who have been physically abused demonstrate a variety of problematic reactions and behaviors including:

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Long Term Problems for Abused & Neglected Children
  • depression
  • anxiety disorders
  • substance abuse
  • suicidality
  • sexual dysfunctions
  • interpersonal difficulties
  • Posttraumatic stress disorder (PTSD)

Children who have been physically abused demonstrate a variety of problematic reactions and behaviors including:

  • Substance abuse
  • Criminal behavior
  • Violent behavior
  • Poor interpersonal relationships

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From the website: Adopting.org
Foster parents provide a temporary, safe home for children in crisis. They are part of the child's support, treatment, and care programs. They are partners of the child's social worker, attorney, teachers, and doctors. Being a foster parent is not a passive act of opening one's home and providing food, clothing, and shelter. It is a proactive statement of nurturing, advocacy, and love.
Children who need foster families have been removed from their birth family homes for reasons of neglect, abuse, abandonment, or other issues endangering their health and/or safety. Many of these children are filled with fear, anger, confusion, or a sense of powerlessness at having been removed from the only home they have ever known. Many are sibling groups, older children, or young teens. Some have developmental, physical, emotional, or behavioral problems.

They all need safe, supportive environments.

Can you?

These are questions to ask yourself before taking the next step:
  • Can you love and care for a child who has come from a difficult background?

  • Can you help a child develop a sense of belonging in your home even though the stay is temporary?

  • Can you love a child who, because of a fear of rejection, does not easily love you back?

  • Are you secure in yourself and your parenting skills?

  • Can you set clear limits, and be both firm and understanding in your discipline?

  • Do you view bed-wetting, lying, defiance, and minor destructiveness as symptoms of a child in need?

  • Can you tolerate major failures and small successes?

  • Can you accept assistance and guidance from trained social workers?

  • Can you maintain a positive attitude toward a child's parents; even though many of the problems the child is experiencing is a direct result of the parent's actions?

  • Can you love with all of your heart and then let go?
Financial assistance

All states offer financial support. The amount varies from state to state, but in all cases, you must be able to prove that your current family needs can be met without having to use any of this income. Many states also offer clothing, daycare and/or day camp allowances. Check
foster care rates and requirements in your state.

Other requirements

Requirements to become a foster parent vary from state to state, but this list from the
National Foster Parent Association covers the basics. Be sure to check with the Foster Care Specialist (or equivalent) in your state or province for detailed information.
  • Be at least 21 years old.

  • Have enough room (and beds) in your home for a foster child to sleep and keep his or her belongings.

  • Live in a home that can meet basic fire, safety and sanitary standards.

  • Be physically and emotionally capable of caring for children and have no alcohol or drug abuse problems.

  • Be able to pass a criminal background check and have no substantiated record of abusing or neglecting children.

  • Make enough money to provide for your own family, so you do not need to depend on the foster care reimbursement you receive from the state as income.

Pre-placement training is required to help prepare prospective parents for issues that can arise after a child or sibling group is placed with them. Many children bring not only unique special needs, but a history of life experiences that may affect interactions with foster parents, other children in the family, school mates, and others. Issues related to disability, culture, early abuse, birth family members, etc., should be discussed with your social worker to your satisfaction.

These programs go by various names (MAPP and others) and
online training programs are also available. Your foster care specialist can provide more information, and check the Resources Page for more information.

source site: click here to visit Adoption.org

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PEDIATRICS Vol. 106 No. 5 November 2000, pp. 1145-1150

Developmental Issues for Young Children in Foster Care

Committee on Early Childhood, Adoption and Dependent Care

Greater numbers of young children with complicated, serious physical health, mental health, or developmental problems are entering foster care during the early years when brain growth is most active. Every effort should be made to make foster care a positive experience and a healing process for the child. Threats to a child's development from abuse and neglect should be understood by all participants in the child welfare system. Pediatricians have an important role in assessing the child's needs, providing comprehensive services, and advocating on the child's behalf.

The developmental issues important for young children in foster care are reviewed, including:

1) the implications and consequences of abuse, neglect, and placement in foster care on early brain development;

2) the importance and challenges of establishing a child's attachment to caregivers;

3) the importance of considering a child's changing sense of time in all aspects of the foster care experience; and

4) the child's response to stress.

Additional topics addressed relate to parental roles and kinship care, parent-child contact, permanency decision-making, and the components of comprehensive assessment and treatment of a child's development and mental health needs.

More than 500 000 children are in foster care in the United States.1,2 Most of these children have been the victims of repeated abuse and prolonged neglect and have not experienced a nurturing, stable environment during the early years of life. Such experiences are critical in the short- and long-term development of a child's brain and the ability to subsequently participate fully in society.3-8

Children in foster care have disproportionately high rates of physical, developmental, and mental health problems1,9 and often have many unmet medical and mental health care needs.10 Pediatricians, as advocates for children and their families, have a special responsibility to evaluate and help address these needs.

Legal responsibility for establishing where foster children live and which adults have custody rests jointly with the child welfare and judiciary systems. Decisions about assessment, care, and planning should be made with sufficient information about the particular strengths and challenges of each child.

Pediatricians have an important role in helping to develop an accurate, comprehensive profile of the child. To create a useful assessment, it is imperative that complete health and developmental histories are available to the pediatrician at the time of these evaluations. Pediatricians and other professionals with expertise in child development should be proactive advisors to child protection workers and judges regarding the child's needs and best interests, particularly regarding issues of placement, permanency planning, and medical, developmental, and mental health treatment plans.

For example, maintaining contact between children and their birth families is generally in the best interest of the child, and such efforts require adequate support services to improve the integrity of distressed families. However, when keeping a family together may not be in the best interest of the child, alternative placement should be based on social, medical, psychological, and developmental assessments of each child and the capabilities of the caregivers to meet those needs.

Health care systems, social services systems, and judicial systems are frequently overwhelmed by their responsibilities and caseloads. Pediatricians can serve as advocates to ensure each child's conditions and needs are evaluated and treated properly and to improve the overall operation of these systems. Availability and full utilization of resources ensure comprehensive assessment, planning, and provision of health care.

Adequate knowledge about each child's development supports better placement, custody, and treatment decisions. Improved programs for all children enhance the therapeutic effects of government-sponsored protective services (e.g., foster care, family maintenance).

The following issues should be considered when social agencies intervene and when physicians participate in caring for children in protective services.

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Early Brain and Child Development

More children are entering foster care in the early years of life when brain growth and development are most active.11-14 During the first 3 to 4 years of life, the anatomic brain structures that govern personality traits, learning processes, and coping with stress and emotions are established, strengthened, and made permanent.15,16

If unused, these structures atrophy.17 The nerve connections and neurotransmitter networks that are forming during these critical years are influenced by negative environmental conditions, including lack of stimulation, child abuse, or violence within the family.18 It is known that emotional and cognitive disruptions in the early lives of children have the potential to impair brain development.18

Paramount in the lives of these children is their need for continuity with their primary attachment figures and a sense of permanence that is enhanced when placement is stable.10 There are critical periods of interaction among physical, psychological, social, and environmental factors. Basic stimulation techniques and stable, predictable nurturance are necessary during these periods to enable optimal cognitive, language, and personal socialization skills.

Because these children have suffered significant emotional stress during critical periods of early brain development and personality formation, the support they require is reparitive; as well as preventive. The pediatrician, with knowledge of the child's medical and family history, may assist the social service and judicial systems in determining the best setting to help the child feel safe and heal.

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To develop into a psychologically healthy human being, a child must have a relationship with an adult who is nurturing, protective, and fosters trust and security.19

Attachment refers to this relationship between 2 people and forms the basis for long-term relationships or bonds with other persons. Attachment is an active process - it can be:

  • secure or insecure
  • maladapative or productive.

Attachment to a primary caregiver is essential to the development of emotional security and social conscience.20

Optimal child development occurs when a spectrum of needs are consistently met over an extended period. Successful parenting is based on a healthy, respectful, and long-lasting relationship with the child.

This process of parenting, especially in the psychological rather than the biologic sense, leads a child to perceive a given adult as his or her "parent." That perception is essential for the child's development of self-esteem and self-worth.21

A child develops attachments and recognizes as parents adults who provide "... day-to-day attention to his needs for physical care, nourishment, comfort, affection, and stimulation."21

Abused and neglected children (in or out of foster care) are at great risk for not forming healthy attachments to anyone.9,10 Having at least 1 adult who is devoted to and loves a child unconditionally, who is prepared to accept and value that child for a long time, is key to helping a child overcome the stress and trauma of abuse and neglect.

The psychosocial context and the quality of the relationship from which a child is removed, as well as the quality of alternative care that is being offered during the separation, must be carefully evaluated. This information should be used to decide which placement is in the child's best interest.

The longer a child and parent have had to form a strong attachment with each other (i.e., the older the child) the less crucial the physical proximity will be to maintain that relationship.

Separation during the first year of life - especially during the first 6 months - if followed by good quality of care thereafter, may not have a deleterious effect on social or emotional functioning. Separations occurring between 6 months and about 3 years of age, especially if prompted by family discord and disruption, are more likely to result in subsequent emotional disturbances.

This partly results from the typical anxiety a child this age has around strangers and the normal limitations of language abilities at this age. Children older than 3 or 4 years placed for the first time with a new family are more likely to be able to use language to help them cope with loss and adjust to change.

These preschool-aged children are able to develop strong attachments and, depending on the circumstances from which they are removed, may benefit psychologically from the new setting.

The emotional consequences of multiple placements or disruptions are likely to be harmful at any age, and the premature return of a child to the biologic parents often results in return tofoster care or ongoing emotional trauma to the child.22 Children with attachment disorders and an inability to trust and love often grow up to vent their rage and pain on society.19

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Children's Sense of Time
Children are placed in foster care because of society's concern for their well-being. Any time spent by a child in temporary care should be therapeutic but may be harmful to the child's growth, development, and well-being. Interruptions in the continuity of a child's caregiver are often detrimental.
Repeated moves from home to home compound the adverse consequences that stress and inadequate parenting have on the child's development and ability to cope. Adults cope with impermanence by building on an accrued sense of self-reliance and by anticipating and planning for a time of greater constancy.
Children, however, especially when young, have limited life experience on which to establish their sense of self. In addition, their sense of time focuses exclusively on the present and precludes meaningful understanding of "temporary" versus "permanent" or anticipation of the future.
For young children, periods of weeks or months are not comprehensible. Disruption in either place or with a caregiver for even 1 day may be stressful. The younger the child and the more extended the period of uncertainty or separation, the more detrimental it will be to the child's well-being.21

Any intervention that separates a child from the primary caregiver who provides psychological support should be cautiously considered and treated as a matter of urgency and profound importance. Pediatricians should advocate that evaluation, planning, placement, and treatment decisions be made as quickly as possible, especially for very young children.

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The body's physiologic responses to stress are based on involuntary actions of the brain. Physical and mental abuse during the first few years of life tends to fix the brain in an acute stress response mode that makes the child respond in a hypervigilant, fearful manner.18,22

Research demonstrates chemical and electrical evidence for this type of brain response pattern.18,23 The age of the child dictates the developmental response and manifestations to stress. When an infant is under chronic stress, the response may be:

  • apathy
  • poor feeding
  • withdrawal
  • failure to thrive

When the infant is under acute threat, the typical "fight" response to stress may change from crying (because crying did not elicit a response) to:

  • temper tantrums
  • aggressive behaviors
  • inattention 
  • withdrawal24

The child, rather than running away (the "flight" response), may learn to become:

  • psychologically disengaged, leading to detachment
  • apathy
  • excessive daydreaming

Some abused and neglected children learn to react to alarm or stresses in their environment reflexively with immediate cessation of motor activity (freeze response). Older children who have been repeatedly traumatized often suffer from post traumatic stress disorder and automatically freeze when they feel anxious, and therefore are considered oppositional or defiant by those who interact with them. 

The same areas of the brain that are involved in the acute stress response also mediate motor behavior and such functions as state regulation and anxiety control.23 Repeated experiencing of traumatic events can lead to dysregulation in these various functions resulting in behaviors such as:

  • motor hyperactivity
  • anxiety
  • mood swings
  • impulsiveness
  • sleep problems.18

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Effects of Neglect
An increasing number of young children are being placed in foster care because of parental neglect.1 Neglect has very profound and long-lasting consequences on all aspects of child development -
  • poor attachment formation
  • under-stimulation
  • development delay
  • poor physical development
  • antisocial behavior.8,17,25-27

Being in an environment in which child-directed support and communication is limited makes it more difficult for a child to develop the brain connections that facilitate language and vocabulary development, and therefore may impair communication skills.28

Recent findings in infant mental health show how development can be facilitated, how treatment can enhance brain development and psychological health, and how prevention strategies can lessen the ill effects of neglect.29

Comprehensive Assessment Of The At-Risk Child - Before Placement

Knowledge of normal child development and family functioning helps identify children receiving insufficient and inappropriate care as well as children who are victims of, or at risk for, abuse or neglect. Comprehensive pediatric assessments can complement programs that prevent abuse and neglect, decrease the likelihood of placement in foster care, identify whether a child's current needs are being met, and allow placements to be customized to meet each child's needs.

Comprehensive Assessment Of Children - After Placement

A pediatric assessment should be done within 30 days of placement.30 This evaluation must be:

  1. Comprehensive: Appropriate in breadth and depth, assessing physical, behavioral, emotional, cognitive, relational, and environmental domains.

  2. Integrative: Address the effect any 1 domain of function has on another domain of function (e.g., impact of motor deficits on speech).

  3. Developmental: Age-appropriate using validated instruments that are sensitive to changes in development over time.

  4. Preventive: Anticipatory, focusing on early identification and interventions.

  5. Longitudinal: Based on data collected over time to determine problems, each child's abilities, and future course.

  6. Summative: Able to synthesize and compile results for the purpose of prioritization.

  7. Culturally Sensitive: Sensitive to different values, meanings, and perceptions of importance.

  8. Child-Sensitive: Conducted in settings and in a manner that protects the child's comfort and that controls and limits the stress of the evaluation.

  9. Standardized: Sensitive, specific, valid, and reliable.

  10. Child Welfare-Sensitive: Consistent with norms, standards, and goals of child welfare.

  11. Parsimonious: Compact, efficient, and able to be completed in a reasonable amount of time.

At a minimum, the following areas should be assessed:

  • Gross motor skills
  • Fine motor skills
  • Cognition
  • Speech and language function
  • Self-help abilities
  • Emotional well-being
  • Coping skills
  • Relationship to persons
  • Adequacy of caregiver's parenting skills
  • Behaviors

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The comprehensive assessment should lead to an individualized court-approved treatment plan and ongoing monitoring by a multidisciplinary team skilled in working with this population in the context of a medical home.31

In-home monitoring, placement with a relative ("kinship care"), or out-of-home placement should support each child's psychological and developmental needs. Parents and foster parents must be well-informed about the importance of the environment in the development of normal brain function and the specifics needed for the child under care.

Children can often be helped by providing predictability, nurturance, support, and cognitive or insight-oriented interventions to make them feel safe, comfortable, and loved. Specific mental health plans must be developed to meet the functional needs of each child.

Early interventions are key to minimizing the long-term and permanent effects of traumatic events on the child's brain.14,17,32-36

After the first several years of a child's life, patterns of interaction with the world are formed, both psychologically and in the brain structure, making it more difficult, though still possible, to improve a child's physical, cognitive, and emotional abilities.17

Several studies have shown how favorable and stimulating environments for infants and young children can lessen the adverse effects of prior negative environments.27 Pediatricians have an important role in recognizing problem situations in the home and for children already in foster care. Prompt referrals should be made for early intervention services to secure full developmental assessments and treatments under the Individuals With Disabilities Act.

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Placement Issues

Courts with jurisdiction over families and children have been charged by Congress and the states to ensure that "reasonable efforts" are made to preserve and repair families or to place children in foster care when necessary. The courts also have the responsibility to make foster care a healing process.

Given limited social, economical, educational, and health care resources, the judiciary has a responsibility to try to make needed resources available in the community and to decide whether application of available resources has been reasonable and appropriate. An array of supportive services should be available to assist families in child rearing and to offer alternative and therapeutic parenting(i.e., foster care) when temporary removal of the child from the home is required.

The measure of reasonable and appropriate should always be what is in the best interests of the child. Lack of agreement exists about what constitutes such reasonable efforts. Principles of child development and expert consultation can provide guidance to assist in determining what is in the best interest of the child and whether these interests can be best met within the biologic family or another family. The lack of available resources to ensure a reasonable effort should not be used by the protective services agencies as an excuse to delay a permanent placement plan for a child.

Parental Roles and Kinship Care

The increasing number of children entering foster care, the insufficient number of suitable foster homes, and the increased interest by extended families to care for their kin have led social service agencies to place children with their extended families.

Placement with a relative has psychological advantages for a child in terms of knowing his or her biologic roots and family identity. It may offer a better chance for stability and continuity of care giving. However, little is known about the outcomes of kinship placement, and it should not be assumed to offer a superior home environment.37

Supervision by social workers of relatives providing foster careis often less intense and family support services are less available than when a child is placed in non-kinship foster care. Placement with a relative may lead to a circuitous and unintended return of the child to his or her parents.

The report by the National Commission on Family Foster Care states: "The use of kinship care has expanded so rapidly that child welfare agencies are making policy, program, and practice decisions that lack uniformity and/or a substantive knowledge base.

Kinship care provides an opportunity to affirm the value of families. But the assessment process and support should include unique family strengths and needs, cultural and ethnic identification, necessary financial and service supports, continuity of care, and permanency goals."38

Studies suggest that a range of parenting arrangements can provide the feelings of permanency, security, and emotional constancy necessary for normal development.39

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Visiting (Parent - Child Contact)

Children in out-of-home dependent care are usually accorded a schedule of visits with their parents. The intent is to maintain or improve the child-parent relationship, to give the social service agency an opportunity to observe and improve the parent-child interaction, and to monitor the parents' progress. The visits are frequently brief encounters occurring on a weekly basis, in a neutral setting if possible, often under the supervision of a caseworker.

For younger children, this type of visit is not conducive to optimal parent-child interaction and may minimally serve the parents' needs for ongoing contact with the child or may even be harmful for the child.

A young child's trust, love, and identification are based on uninterrupted, day-to-day relationships. Weekly or other sporadic "visits" stretch the bounds of a young child's sense of time and do not allow for a psychologically meaningful relationship with estranged biologic parents. For older children, such sporadic and brief visits may be sufficient to maintain a meaningful parent-child relationship.

For parent-child visits to be beneficial, they should be frequent and long enough to enhance the parent-child relationship and to effectively document the parent's ongoing interest and involvement with the child. Sporadic visits are appropriate if an older child has established a strong attachment to the parent before entering foster care or if the visits are sufficient in frequency, length, and content to contribute to the child's continuing normal development and enhanced parent-child relationship.

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Stable Placement Versus Legal Custody Versus Permanence

Children who have experienced abuse or neglect have a heightened need for permanency, security, and emotional constancy and are, therefore, at great risk because of the inconsistencies in their lives and the foster care system. Every effort should be made to rapidly establish a permanent placement for the child. Tangible continuity in relationships with family and friends is essential for a child's healthy development.

Stability in child care and the school environment is important. Multiple moves while in foster care (with the attendant disruption and uncertainty) can be deleterious to the young child's brain growth, mental development, and psychological adjustment.

All children, regardless of their type of placement, must receive individual attention from their caregivers. Foster parents and extended family members can play a significant role when the child's mother or father cannot. Impersonal placement settings do not effectively support young children who have been abused and neglected.

Bureaucratic proceedings, including conferring legal status, are usually of little or no consequence to children, whose needs are much more fundamental. Generally, assignment of custody should reinforce a child's perception of belonging and should not disrupt established psychological ties except when safety or emotional well-being are in jeopardy.

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All placement, custody, and long-term planning decisions should be individualized for the child's best interest and should maximize the healing aspects of government-sponsored protective services. These decisions should be based in part on a comprehensive assessment and periodic reassessment of the child and family by professionals who are experts in pediatrics and child development (e.g., pediatrician, psychiatrist, or psychologist).22

An ongoing relationship between the pediatrician and the child and family can provide valuable insights about a child's needs and the ability of a family to meet them. Pediatricians should actively participate in prevention services for at-risk families and placement, custody, and long-term planning decisions for children for whom they provide care, taking into account the following considerations.40

The following important concepts should guide pediatricians' activities as they advocate for the child:

  1. Biologic parenthood does not necessarily confer the desire or ability to care for a child adequately.

  2. Supportive nurturing by primary caregivers is crucial to early brain growth and to the physical, emotional, and developmentalneeds of children.

  3. Children need continuity, consistency, and predictability from their caregiver. Multiple placements are injurious.

  4. Attachment, sense of time, and developmental level of the child are key factors in their adjustment to environmental and internal stresses.

  5. Pediatricians can play a constructive role in the referral, assessment, and treatment of children who are at risk for being abused, neglected, or abandoned or who are involved in the protective services system.

  6. Pediatricians need to encourage caregivers to:

    • give the child plenty of love and attention.

    • be consistent with love, stimulation, and discipline.

    • stimulate the child through exposure to developmentally appropriate holding, conversation, reading, music, and toys.

    • expose the child to opportunities to improve language via direct voice and face-to-face contact.

    • match the environment to the child's disposition.

7. Parents should be given reasonable assistance and opportunity to maintain their family, while the present and future best interests of the child should determine what is appropriate.

8. A child's attachment history and sense of time should guide the pace of decision-making.

9. Foster care placements should always maximize the healing aspects of foster care and be based on the needs of the child.

10. Foster care placement with relatives should be based on a careful assessment of the needs of the child and of the ability of the kinship care to meet those needs. As with all foster care placements, kinship care must be supported and supervised adequately.

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Child Abuse - The Hidden Bruises

The statistics on physical child abuse are alarming. It's estimated hundreds of thousands of children are physically abused each year by a parent or close relative. Thousands die.

For those who survive, the emotional trauma remains long after the external bruises have healed. Communities and the courts recognize that these emotional “hidden bruises” can be treated.

Early recognition and treatment is important to minimize the long term effect of physical abuse. Whenever a child says he or she has been abused, it must be taken seriously and immediately evaluated.

Children who have been abused may display:

  • a poor self image
  • sexual acting out
  • inability to trust or love others
  • aggressive, disruptive and sometimes illegal behavior
  • anger and rage
  • self destructive or self abusive behavior, suicidal thoughts
  • passive, withdrawn or clingy behavior
  • fear of entering into new relationships or activities
  • anxiety and fears
  • school problems or failure
  • feelings of sadness or other symptoms of depression
  • flashbacks, nightmares
  • drug and alcohol abuse
  • sleep problems

Often the severe emotional damage to abused children doesn't surface until adolescence or later, when many abused children become abusing parents. An adult who was abused as a child often has trouble establishing intimate personal relationships.

These men and women may have trouble with physical closeness, touching, intimacy and trust as adults. They're also at higher risk for anxiety, depression, substance abuse, medical illness and problems at school or work. Without proper treatment, physically abused children can be damaged for life.

Early identification and treatment is important to minimize the long-term consequences of abuse. Qualified mental health professionals should conduct a comprehensive evaluation and provide treatment for children who have been abused.

Through treatment, the abused child begins to regain a sense of self-confidence and trust. The family can also be helped to learn new ways of support and communicating with one another. Parents may also benefit from support, parent training and anger management.

Physical abuse isn't the only kind of child abuse. Many children are also victims of neglect, or sexual abuse, or emotional abuse. In all kinds of child abuse, the child and the family can benefit from evaluation and treatment from a qualified mental health professional.

Source: AACAP No. 5; Updated July 2004

National Facts About Children in Foster Care 

Total Population:
513,000 children were in the U.S. foster care system on September 30, 2005. Most children are placed temporarily in foster care due to parental abuse or neglect.

Age: Average Age: 10.0 years

6% < 1 year
26% 1-5 years
20% 6-10 years
28% 11-15 years
18% 16-18 years
2% >19 years


Male 52%
Female 48%

Race and Ethnicity:
As a percentage, there are more children of color in the foster care system than in the general U.S. population. However, child abuse and neglect occur at about the same rate in all racial / ethnic groups.

Race/Ethnicity In out-of-home care In general population
Black (non-Hispanic) 32% 15%
White (non-Hispanic) 41% 61%
Hispanic 18% 17%
Am. Indian/Alaska Native (non-Hispanic) 2% 1%
Asian/Pacific Islander (non-Hispanic) 1% 3%
Unknown 2% N/A
2 or More Races (non-Hispanic) 3% 4%

Length of Stay
For the children in foster care on September 30, 2005, the average amount of time they had been in the system was 28.6 months. Half of those leaving care that year had been away from home for a year or longer. 54% of the young people leaving the system were reunified with their birth parents or primary caregivers.

Foster Homes
In 2004, there was a total of 153,000 licensed / certified / approved kinship and non-relative foster homes nationwide. In 2005, 24% of youth living foster care were residing with their relatives.

n 2005, 60% of adopted children were adopted by their foster parent(s). The "foster parent" category excludes anyone identified as a relative of the child. 25% of children adopted in FY 2005 were adopted by a relative. A "relative" includes a step-parent or other relative of the child.

Siblings and Extended Families
Over 2 million American children live with grandparents or other relatives because their parents cannot care for them. When relatives provide foster care (known as kinship care), siblings can often stay together. Kinship care also improves stability by keeping displaced children closer to their extended families, their neighborhoods, and their schools.

Youth in Transition
Each year, an estimated 20,000 young people "age out" of the U.S. foster care system. Many are only 18 years old and still need support and services. Several foster care alumni studies show that without a lifelong connection to a caring adult, these older youth are often left vulnerable to a host of adverse situations:

Outcomes National Regional or Local
Earned a high school diploma 54% 50% - 63%
Obtained a Bachelor's degree or higher 2% 2%
Became a parent 84% 42%
Were unemployed 51% 30%
Had no health insurance 30% 29%
Had been homeless 25% 36%
Were receiving public assistance 30% 26%

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Should I Do Foster Care?

Points to Consider

By Carrie Craft, About.com

One day I came home from working at our local children's home and asked my husband what he thought about becoming a foster parent. He had numerous fears and logical concerns. Many men are good about the latter, logical concerns.

We decided the best first step was to take the training classes and go from there. Several months later, we were so nervous when we drove our first foster child home, but we knew we had taken stock of our skills and limitations and decided that we were ready to become foster parents.

After gathering information from your state's foster care agency; ask yourself the following questions:

Do you have a strong support system of friends and/or family?

This is important, as fostering can become very stressful at times. It's good to have someone who will listen if you need to vent. If you don't have a support system already in place and decide to go ahead with fostering, be sure to participate in support groups. Many agencies hold their own support group meetings. If not consider starting your own with other foster parents.

Are you a patient person? Are you willing to continually give and very rarely get anything in return, except for the knowledge that you are helping a family?

Many people enter into foster care thinking that they are rescuing a poor child from an abusive parent. These foster parents believe that the child will be grateful and relieved to be out of their home situation. This is rarely the case.

Abuse is all that the child may know. The child's bad situation is her "normal." Be prepared for the child to be anything but happy about being in your home. In other words, examine your expectations. What are you expecting? Not only from the child, but from his or her parents, the state and the fostering experience itself? High expectations can lead to your fall!

Kids in care have sometimes been neglected, physically, sexually, mentally and emotionally abused. The children can be angry, resentful and sad. They may take it out on their foster parents, usually the foster mother. Are you willing and able to deal with what the children may put on you, and not take it personally? This is harder than it seems, especially when you are being kicked or cussed out.

Are you willing to have social workers in your home, sometimes every month? Can you work in a partnership with a team of professionals to help the child either get back home or to another permanent placement, such as adoption? This goal requires excellent communication skills on your part, and a commitment to follow the plan set forth by the social workers.

Can you say goodbye? Foster care is not a permanent arrangement. The children will move on someday. Permanency is what you want for them. However, you and your family will attach to this child, so don't fool yourself into thinking otherwise. Attachment is a good thing, for both you and the child. If the child can attach and trust you, they will be able to do the same with others in their lives and this leads to a healthier future. Goodbye does not have to mean for forever.

In some cases, with permission from the birth parent or adopted parent, a relationship with your foster children can remain intact after a move. We have a relationship with a few of our past foster daughters and enjoy seeing them and receiving cards and phone calls. They even still ask us for advice.

If you have children, how do they feel about doing foster care? It's important to consider every member of your family when thinking about fostering. Everyone in the house will be living and interacting with the foster child and his behaviors. Your children will have to share their home, room, toys and parents. They sacrifice a lot in becoming part of a fostering family.

Ask your children how they feel and listen! Also, be aware that your child may learn or pick up whatever the foster child knows, both the good and the bad. Are you prepared to stand guard at all times, making your home safe for all who live there?

What ages of children can you parent at this time? Consider the ages of your own children and where another child would fit into your family. Is a baby right for you? While you won't have to deal with foul language, you will have to give up sleep and basically "start over" if your children are grown. Or would a school age child work better. In this situation you may not have to worry about day care.

Also, consider the sex of the child. These are choices that are all up to you as a foster parent. You will also be given choices on what behaviors that you feel you can and cannot parent at this time. Be aware of the fact that many behaviors may not surface until the child feels safe enough to be himself. The social workers are also not always aware of a child's behavior at the time of placement.

Finally, do you have a lot of love to give? Are you ready to throw a child her first birthday party? Can you help him decorate a first Christmas tree or carve a first pumpkin? Help the child to see that families are a great place to grow up and show him an excellent role model of healthy family relationships? Give her an opportunity to heal and grow?

If you can say "yes" to most of these questions, then call your state foster care representative. You have an excellent chance of being a wonderful foster parent!

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When children blame themselves for their parents' unhappiness

1 September 2008

No surprise to learn from new UK research that children whose parents fight run a high risk of underachieving at school. But the evidence being assembled by Gordon Harold and his Cardiff University colleagues is also beginning to explain why, by shedding light on the psychological processes that translate cause into potentially damaging effect.

The link between the family context and children’s psychological development is well established. There are known connections between levels of psychological adjustment (particularly in relation to their emotions and behavior) and factors such as parental mental illness and divorce – as well as inter-parental conflict.

However, investigations such as those by Cardiff's School of Psychology are extending the range of the known effects by unpicking the broader family context and examining other aspects of children’s development.

The study tracked the experience of 230 UK schoolchildren aged between 11 and 13 and that of their parents and teachers over a two-year period (1999-2001). Researchers cataloged children’s and parents’ reports of inter-parental conflict, as well as information about the parent-child relationship, the children’s appraisals of inter-parental conflict, teachers’ reports of children’s behavior, and children’s scores on Key Stage Three standardized academic tests (SATs).

The findings suggest that children living in households characterized by high levels of inter-parental conflict are indeed at risk of lower attainment at school, and, importantly, that children’s own appraisal of their parents’ conflict and their tendency to blame themselves for what they see happening is the mechanism through which any damage is done. Self-blaming was found to lead to lower academic attainment and, in some cases, to aggressive behavior.

Some clear lessons for researchers, practitioners and policy makers are emerging. For example, the finding that the inter-parental relationship has a direct influence on the development of the child is a strong argument for early intervention, particularly in light of the fact that academic success is consistently shown to be an important predictor of adult adjustment.

Secondly, such services should surely involve direct work with child as well as parents if they are to deal with the condition of self-blame that seems to have the power to translate the risk factor of inter-parental conflict into negative outcomes for children.

• Summary of Harold G T, Aitken J, Shelton K H. (in press) "Inter-parental Conflict and Children’s Academic Attainment: A longitudinal analysis", Journal of Child Psychology and Psychiatry.

• first published in Prevention Action on November 15th 2007

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 When a Parent Has a Mental Illness: Issues and Challenges



Mental illness can cause mild to severe disturbances in thought and behaviors and can result in an inability to cope with life's ordinary demands and routines. Consequently, it can have a significant impact on family stability. Parents with mental illness have lower marriage and higher divorce rates than the general population. Some parents with mental illness may face problems with parent-child attachment due to repeated separations or family instability.1 Therefore, families with a parent who has a mental illness require unique services that include both prevention and intervention services for the parent and child(ren). The issues and challenges faced by the one in four American families affected by mental illnesses, such as depression, anxiety disorders and schizophrenia, are numerous and varied.2 These issues, which are explored in greater detail in other fact sheets in this series, include:

  • The impact of mental illness on parenting capacity.
  • The impact of parental mental illness on children.
  • The stigma surrounding mental illness.
  • Legal issues - parents maintaining custody and contact with their children.
  • Need for integrated services for parents and families.

Impact of Mental Illness on Parenting Capacity

Mothers and fathers with mental illness experience all of the challenges of other adults attempting to balance their roles as workers, spouses and parents. The symptoms of mental illness, however, may inhibit these parents' ability to maintain a good balance at home and may impair their parenting capacity. When parents are depressed, for example, they may become less emotionally involved and invested in their children's daily lives. Consequently, parent-child communication may be impaired.3 The severity of a parent's serious mental illness and extent of the symptoms may be a more important predictor of parenting success than diagnosis.

To be effective, intervention programs and supports for families need to be comprehensive, addressing the needs of the whole family. Services should also be long-term, supporting the family until their primary needs are addressed.

Impact of Parental Mental Illness on Children

The impact of parental mental illness on family life and children's well-being can be significant. Children whose parents have a mental illness are at risk of developing social, emotional and/or behavioral problems. The environment in which children grow affects their development and emotional well-being as much as their genetic makeup does.

Service providers and advocates working with families in which a parent has a mental illness have identified a number of challenges faced by their children. For example, children may take on inappropriate levels of responsibility in caring for themselves and managing the household. Children sometimes blame themselves for their parents' difficulties, and experience anger, anxiety or guilt. Feeling embarrassed or ashamed as a result of the stigma associated with their parents' mental illness, they may become isolated from their peers and other community members. They may be at increased risk for problems at school, drug use and poor social relationships. Children of parents with any mental illness are at risk a range of mental health problems, including mood disorders, alcoholism, and personality disorders.

Despite these challenges, many children of parents with mental illness are resilient and are able to thrive in spite of genetic and environmental vulnerability. Resiliency is directly proportionate to the number of risk and protective factors present within the family: the greater number of protective factors and smaller number of risk factors, the greater the likelihood of a child being resilient. Therefore, services for families and children should include opportunities to reduce risk and enhance resiliency.

The Stigma Surrounding Mental Illness

The most pervasive factor affecting parents' access to and participation in mental health services is the stigma accompanying mental illness.4 The stigma of mental illness is likely borne out of misconceptions of mental illness and exacerbated by disproportionate media misrepresentations of people with mental illnesses as violent or unfit. The stigma keeps many parents from seeking the help they need,5 particularly in cases where they are afraid of losing custody of their children. The stigma of mental illness is more severe than that of other serious or chronic conditions like heart disease, diabetes, and cancer. Being labeled with a psychiatric disorder can profoundly and negatively affect the experiences of parents and their family members, adults and children alike.

Legal Issues - Parents Maintaining Custody and Contact with their Children

Parents with mental illness may be quite vulnerable to losing custody of their children. Some studies have reported as many as 70 percent of parents have lost custody.6 The primary reason for custodial challenge is the stigma surrounding mental illness. Many people believe that consumers of mental health services are naturally unfit as parents. Another common misconception is that parents with mental illness are violent and are therefore at increased risk for abusing their children.

As a result, many families find themselves in a "no win" cycle of loss. They are aware that if they openly seek help, their symptoms may give an impression of unfitness. Therefore, these families may not seek the services or supports they need, and without those services their parenting capacity is diminished. In cases where a state government determines it to be in the child's best interest to remove the child from the home, the child may end up in temporary or permanent substitute care.

Need for Integrated Services for Parents and Families

Addressing the needs of families in which a parent has a mental illness requires a shift in the way most health and human service systems operate. Providing family centered care is essential. However, the current managed care emphasis on time-limited treatment and the narrow focus on symptom management are incompatible with a treatment approach that includes the whole family.

Treatment is most effective when multiple systems work together. For example, schools should provide more mental health consultation to students, foster social competencies, provide support for students in transition, and encourage peer support and counseling. The child welfare system could provide caseworker training related to parents with mental illness and cross-training in adult and child issues. Communities should invest in improved prenatal care and expand access to high-quality childcare to help a range of vulnerable families.


1. American Academy of Child and Adolescent Psychiatry. Children of Parents with Mental Illness. No. 39. May, 2000.

2. Context of Parenting. May, 1998. Vol. 49. No. 5.

3. Roberta Sands. “The Parenting Experience of Low-Income Single Women with Serious Mental Disorders. Families in Society.” The Journal of Contemporary Human Services. 76 (2), 86-89. 1995.


4. Ibid.


5. Virginia Child Protection Newsletter. “Parents With Serious Mental Illness.” Vol. 56. Summer, 1999. Critical Issues For Parents With Mental Illness and Their Families. Center for Mental Health Services. July, 2001.


6. Joanne Nicholson, Elaine Sweeny, and Jeffrey Geller. Mothers With Mental Illness: II. Family Relationships and the Context of Parenting. May 1998. Vol.49. No. 5.

This fact sheet is made possible through an unrestricted educational grant from The E.H.A. Foundation.

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