CHILDREN in out-of-home care are numerous, and particularly vulnerable to poor developmental outcomes. Those younger than 6 years form the largest cohort of children entering care, and remain longest in care. According to data published by the Adoption and Foster Care Analysis and Reporting System (AFCRS Report; U.S. Department of Health and Human Services, 2003), there were 542,000 children in foster care on September 30, 2001. Nearly 154,000 were younger than 5 years. Data provided by the Multistate Foster Care Data Archive (Wulczyn, Brunner Hislop, & Jones Harden, 2002) indicate that 21% of children entering care between 1990 and 1998 were younger than 1 year. Infants remained in care twice as long as older children, and were less likely to be reunified with their biological families. Twenty-seven percent returned to care after reunification.
The most common reasons for removing children from their biological parents are neglect and parental incapacity. In different samples and using somewhat different criteria, investigators (Chernoff, Combs-Orme, Risley-Curtiss, & Heisler, 1994; Silver, DiLorenzo, Zukoski, Ross, Amster, & Schlegel, 1999; Takayama, Wolfe, & Coulter, 1998) have identified principal reasons for foster placement: neglect (30%–59% of children); parental incapacity, including substance abuse and/or mental illness (30%–75%); physical abuse (9%–25%); abandonment (9%–23%), and sexual abuse (2%–6%).
The majority of children in foster care have medical, mental health, and/or developmental problems. It has been estimated that they have 3 to 7 times as many acute and chronic health conditions, emotional adjustment problems, and developmental delays as other children (Rosenfeld et al., 1997). One investigation identified developmental or emotional problems in 76% of foster children birth to 12 months, 83% of children 13 to 36 months, and 92% of children 37 to 60 months of age (Halfon, Mendonca, & Berkowitz, 1995).
Children's need for out-of-home placement is caused by complex, often interactive, factors that create risk for maltreatment as well as for poor developmental outcomes. Many of the factors are beyond the scope of traditional early intervention, and must be addressed by child welfare, judicial, and substance abuse systems.
Problems experienced by biological parents (substance abuse, mental illness, intellectual limitations, social isolation, domestic violence) increase children's vulnerability to maltreatment (Jaudes & Diamond, 1985; Kaufman, 1991; Knutson, 1995; Maluccio & Ainsworth, 2003; Martinson, 1990; Morrison, Frank, Holland, & Kates, 1999; Verdugo, Bermejo, & Fuertes, 1995). Many parents have themselves been in foster care as children (Simms, 1989).
Child factors increasing parental stress and thereby risk of maltreatment include difficult temperament, poor self-regulation, frequent tantrums, oppositional behavior, and intellectual or physical limitations. Children with disabilities are disproportionately vulnerable to maltreatment. Among children with intellectual disabilities, those with mild impairments may be at greater risk than those with severe impairments, due to higher expectations for them (Verdugo et al., 1995). Stressors for parents include financial and emotional burdens, demands for physical care, difficulties managing challenging behaviors, and disappointment about children's progress (Lessenberry & Rehfeldt, 2004; Martinson, 1990; Strickler, 2001; Verdugo et al., 1995). Cahill, Kaminer, and Johnson (1999) have noted that a level of care that is adequate for a child with typical development may be neglectful for a child with a disability.
Adverse environmental conditions (po-verty, unemployment, poor nutrition, lack of social supports, overcrowding) interact with parent and child factors to increase stress. If reunification is planned, an effort should be made to address these conditions in the intervention plan (eg, identifying community supports, job training, referral for housing services) to ameliorate the stresses that negatively affect parenting competency.
The purpose of the following discussion is to describe the medical problems, mental health problems, and developmental disabilities experienced by young children in foster care, and to explore implications for intervention.
CLINICAL PROBLEMS EXPERIENCED BY YOUNG CHILDREN IN FOSTER CARE
Young children entering foster care are among the nation's most medically fragile children. In their short lives they have generally been exposed to an entire host of significant risk factors jeopardizing their physical health. The vulnerabilities of young children in foster care often stem from a combination of biologic and environmental risk factors. The risk factors typically begin prenatally, with the vast majority of children in foster care born in the setting of maternal drug and/or alcohol abuse to mothers living in poverty. Following birth, parental neglect often due to maternal substance abuse, cognitive impairment, or mental illness further compromises the health of children prior to foster placement.
Studies examining the health status of young children entering foster care have demonstrated high rates of both acute and chronic medical problems. In one study, investigators found that 82% of the children had at least 1, and nearly 29% had 3 or more, chronic medical conditions (Halfon et al., 1995). In another study, more than 90% of children entering foster care had an abnormality in at least one body system, and 12% required antibiotics at entry, indicating the presence of acute medical need (Chernoff et al., 1994).
In utero drug and/or alcohol exposure
It is estimated that at least 80% of children in foster care have had prenatal exposure to maternal drugs (U.S. General Accounting Office, 1994). The most common medical findings in children with this exposure include an increased incidence of prematurity and poor intrauterine growth as well as poor growth of the head (microcephaly; Chasnoff, Griffith, Freier, & Murray, 1992). Approximately 40% of children in foster care are born prematurely or have low birth weight (Halfon et al., 1995). The potential complications of prematurity are many, including respiratory problems, neurologic problems that may lead to cerebral palsy, visual problems, gastrointestinal difficulties, hearing problems, anemia, and continued poor growth. Developmental delays are common.
While the call referring a newborn to social services is most typically linked to positive urine toxicology in the infant for illegal drugs, it is the legal substance typically accompanying the illegal drugs that wreaks the greatest havoc on the developing fetus. Fetal alcohol syndrome, fetal alcohol effects, and alcohol-related neurodevelopmental disorder are all terms referring to findings in the child exposed to excessive alcohol while in utero. This set of conditions is grossly underrecognized, underdiagnosed and undertreated in this very high-risk population. The diagnosis of fetal alcohol syndrome denotes a set of physical, behavioral, and cognitive abnormalities in individuals with known exposure to alcohol in utero. The physical findings include prenatal and postnatal growth deficiency with microcephaly, and minor facial and hand anomalies. Occasional major malformations may be present, including heart, skeletal, and cleft lip/palate. Cognitive abilities vary greatly, with typical functioning in the range of mild mental retardation and particular deficits in language, abstract reasoning, memory, and judgment. Behavioral issues include hyperactivity, attentional problems, poor impulse control, aggression, and problems with social perception.
Maternal drug use places a child at increased risk for congenital HIV infection. This maternal population most likely did not seek timely prenatal care and therefore was not offered the now-available treatments for HIV positive mothers to significantly diminish transmission of the virus to their fetus. Indeed, the population of children in foster care has an increased incidence of HIV infection as well as other vertically transmitted congenital infections such as syphilis, hepatitis, and herpes. In a study of young foster children in 3 major metropolitan areas in 1995, the U.S. General Accounting Office found that 78% of the children were at a high risk for HIV, but only 9% had been tested (U.S. General Accounting Office, 1995). Since that time, HIV testing has been included in the neonatal screen in some states, leading to the potential to better characterize the prevalence of HIV in this high-risk population.
Shaken baby syndrome
Physical abuse has been identified as the reason for removal for 9% to 25% of children in foster care (Chernoff et al., 1994). Infants are the largest subgroup among confirmed cases of abuse (Wulczyn et al., 2002). The most severe form of physical abuse seen in this age group is the “shaken baby syndrome” in which a baby is shaken, usually in the setting of excessive crying, leading to a shearing injury and subsequent subdural and retinal hemorrhages. This form of induced injury has a highly significant mortality rate of 20% to 40%. Of those who survive, more than half have neurologic abnormality, with more than a third in the severe range. Retinal hemorrhages are found in 85% and are associated with significant visual impairment (Johnson, 2000).
Failure to thrive
A fall in weight below the 5th percentile for age is defined as failure to thrive. This is a condition seen more commonly in children in foster care than in the general population. Approximately 40% of infants born small for gestational age remain failure to thrive, perhaps on a constitutional basis. Another group is felt to be “failing to thrive” on an emotional basis related to reactive attachment disorder. Another group is “failing to thrive” because of an undiagnosed chronic medical condition or inadequate nutrition. Whatever the cause, the finding of failure to thrive in infancy increases the likelihood of later developmental delay. This is a medical finding that requires a significant work up to clarify the cause and course of treatment for a particular child (Racine, 2001).
Foster children face exaggerated health risks associated with poverty. Exposure to lead from such source as old paint, dust, soil, lead water pipes, folk remedies, car exhaust, newsprint, and placental transfer occurs to a significant extent in this population. The impact of this exposure is then often magnified by a lack of supervision, the tendency of children with developmental delays to continue to put objects into their mouths at more advanced chronological ages, and medical neglect with delayed recognition and treatment of an elevated level (≥10). Long-term sequelae can include cognitive deficits, language impairment, and behavioral difficulties. Screening guidelines are provided by Weitzman (2001).
Common chronic medical conditions
Common medical diagnoses seen in the population of children in foster care include asthma (35%), short stature (30%), anemia (20%), congenital anomalies (8%), microcephaly (15%), vision (25%) and hearing problems (16%), dermatologic problems (60%), dental caries (>50%), and underimmunization (Chernoff et al., 1994; Halfon et al., 1995, Takayama, Bergman, & Connell, 1994). A common medical/behavioral condition noted in the population of children in foster care is hyperphagia, with the presence of a voracious appetite, and lack of appreciation of satiety, but without excessive weight gain (Ayoob, Kaminer, & Zawell, 1994).
Unmet medical needs
At the point that children enter foster care, they typically have multiple, unmet healthcare needs. We would like to think that upon being placed in foster care those needs are addressed. Yet, several studies looking at the health status of young children in foster care (Chernoff et al., 1994; Halfon et al., 1995, U.S. General Accounting Office, 1995) document that these needs remain unmet, with 12% of children in foster care receiving no routine healthcare, 34% receiving no immunizations, and 32% continuing to have at least one unmet healthcare need after placement.
One reason for continuing medical neglect while in the foster care system relates to the large number of medically/developmentally complex children in care. Caseworkers have large caseloads. They typically cannot follow up on every need of every child personally. This set of responsibilities is thus delegated to the foster parent. The foster parent may not have the background knowledge for dealing with the necessary systems for the care of children with special needs. In conventional families, a responsive parent gets a gradual education when a child has special needs, with additional information and skill gained by the parent over the course of visits with specialists and involvement in ongoing therapeutic programs. The foster parent is not apt to have benefited from this educational process when a foster child with special needs enters care.
A second set of difficulties relates to the lack of availability of medical records on children in foster placement. Although young foster children are apt to have complex medical needs, their foster parents often lack sufficient information to obtain the medical care they require.
Mental health problems
Most of the circumstances that result in foster care placement negatively affect children's social-emotional development. Not surprisingly, therefore, children in foster care have high rates of emotional and behavioral problems. Studies have found that at least 50% of children in foster care, and in some estimates up to 90%, have mental health problems severe enough to warrant clinical intervention (Blatt & Simms, 1997; Harman, Childs, & Kelleher, 2000). Placement in foster care often follows an experience of profound neglect, severe or prolonged physical or sexual abuse, exposure to violence, or grossly disturbed or noncontingent input from a psychiatrically impaired or substance abusing parent. Many children have had multiple caregivers, either before or while in foster care. In the youngest cohort of children entering foster care, these adverse events occur during the most formative time for the development self-regulation and attachment, the primary developmental tasks of infancy and early childhood (Dozier, Albus, Fisher, & Sepulveda, 2002).
Attachment disorders (Zeanah & Boris, 2000) are among the most frequent underlying causes of the emotional and behavioral problems noted in children in foster care. Attachment refers to the special relationship between an infant and a primary caregiver. The nature, quality, and continuity of this relationship shape the infant's emotional life. Secure attachment provides the infant with a sense of safety, a positive sense of self, the tools and experiences through which to regulate emotion, and positive expectations of social experiences and the behavior of others. Infants and toddlers in foster care have frequently endured the loss of their primary attachment figure. Attachment is specific. Loss of the particular adult who provides safety and security is an event that generates overwhelming anxiety, anger, grief, and despair, beginning as early as the second half of the first year of life (Bowlby, 1980).
Because of their intense need for survival and protection, children can and do become attached to adults who abuse or threaten them. Children's capacity to attach reflects their need to feel the safety of familiarity, even with a frightening person (Wallerstein, 2002). Consequently, children suffer as much from being separated from an abusive parent as they do from being separated from a nurturing parent (Hofer, 2003). In addition to the loss of all that is familiar, children who are removed from maltreating adults are highly anxious because of fear of subsequent maltreatment by a stranger. Their “internal working models of attachment,” mental representations that are formed based on past experiences, engender negative expectations of future relationships. The behavior of young children in foster care toward subsequent caregivers, therefore, is often characterized by avoidance and/or anger. These behaviors discourage caregivers from offering nurturance, contributing to the perpetuation of attachment problems (Dozier, Dozier, & Manni, 2002). In addition, foster children's negative attributional biases often result in social problems and aggressive interactions with other children (Dozier, Dozier, et al., 2002).
Children who have experienced grossly pathological care may qualify for a diagnosis of reactive attachment disorder, characterized by markedly disturbed and developmentally inappropriate social relatedness (DSM IV-TR, American Psychiatric Association, 2000). There are 2 types of presentations of reactive attachment disorder. In the inhibited type, the child does not respond to or initiate contact with others, but rather shows extreme trepidation and excessively inhibited, hypervigilant, or highly ambivalent responses toward people. In the disinhibited type, the child exhibits indiscriminate sociability, or a lack of selectivity in the choice of attachment figures. Physical affection toward unfamiliar adults is often observed (Albus & Dozier, 1999).
Young children in foster care often present with regulatory disorders (Zero to Three, 1994). Regulatory disorders are characterized by the infant's or young child's inability to establish regular patterns in sleep or eating, and/or to modulate emotion, attention, activity level, or aggression. All of these contribute to significant management difficulties. Children in foster care are often predisposed to regulatory difficulties due to the neurobiological vulnerabilities created by prenatal exposure to drugs (Mayes, 1999) or prematurity. Furthermore, their regulatory capacities are compromised by the impairments and disruptions in their attachment relationships. Self-regulation begins as a dyadic process. By establishing routines and protecting the infant from excessive levels of arousal or distress, the caregiver helps the infant develop the capacity for self-regulation. Children who have experienced aberrant care often show deficits in self-regulation because they have been overwhelmed by intolerable levels of anxiety or discomfort, have experienced extreme unpredictability in their caregiving environments, and/or because they have had adult models of poorly regulated behavior. Sleep disorders are common, and are exacerbated by anxiety, the young child's fear of being in a vulnerable sleeping position or of giving up an alert state, or because of limited experience with patterned routines of behavior in an earlier caregiving context (Morrison et al., 1999).
Traumatic stress disorder
Many young children in foster care have been traumatized by physical abuse, sexual abuse, or exposure to violence. Behavioral symptoms need to be evaluated carefully to determine if the child meets the criteria for posttraumatic stress disorder, or traumatic stress disorder as it is referred to for the youngest children (Zero to Three, 1994). Children who have been traumatized often have externalizing behaviors, including hyperarousal, hypervigilance, and difficulty concentrating, that might be confused with attention deficit disorder, but require very different types of intervention. There is evidence to suggest that chronic experiences of alarm in infancy prime the brain-mediated stress system to be more readily activated during subsequent threatening situations, leading to a more chronically sensitized state of arousal (Perry, Pollard, Blakely, Baker, & Vigilante, 1995). Traumatized children have recurrent and intrusive memories of the traumatic event(s), and often show marked distress at reminders of the event. Sleep problems, including nightmares or night terrors, are common. Internalizing symptoms can include withdrawal, diminished interests, and in the more severe cases, dissociative behaviors. Developmental regression is common, as is the onset of new fears and anxieties. The play of traumatized children often reflects the traumatic experience and provides an opportunity to reconstruct the child's history if the presence of trauma has not previously been discerned (Scheeringa, Zeanah, Myers, & Putnam, 2002).
Many young children in foster care have developmental disabilities. In a study of more than 200 foster children, Halfon et al. (1995) documented disabilities for young children aged 13 to 36 months and 37 to 60 months. Cognitive disabilities were identified for 30% of the younger group and 37% of the older group, expressive language impairment for 55% and 63%, receptive language impairment for 38% and 44%, and fine motor problems for 27% and 31%, respectively. Two studies of foster children aged 3 years or younger identified mild or significant cognitive delays for 47% of children seen at a hospital-based clinic, and 66% of a group previously screened and referred for more comprehensive evaluation. Motor delays were found for 49% and 46%, respectively (Klee, Kronstadt, & Zlotnick, 1997; Leslie, Gordon, Ganger, & Gist, 2002).
Why do so many children in foster care have developmental disabilities? Maltreatment can itself be the cause of developmental problems in children through physical abuse or neglect involving inadequate supervision. Jaudes and Shapiro (1999) provide a comprehensive review of the forms of maltreatment associated with child disabilities: brain injury, near-miss drowning, asphyxiation, spinal cord injury, burns, and prenatal exposure to alcohol or other drugs.
Neglect has been specifically linked to children's developmental delays, intellectual limitations, and language problems. Neglect can result in delays through parental failure to provide appropriate stimulation, supervision, and guidance. Parental cognitive limitations have been associated with neglect in studies by Feldman et al. (1992); Kaufman (1991); and Verdugo et al. (1995). The possibility of a genetic connection between parental intellectual limitations and child delays should also be considered. In studies involving mothers with mental retardation, 60% of their children had IQs below 85, including 35% with IQs below 70 (Feldman & Walton-Allen, 1997); 86% of children had IQs below 85, including 43% with IQs below 70 (Martin, Ramey, & Ramey, 1990); and 47% of children not receiving early intervention had IQs below 75 (Ramey & Ramey, 1992).
The presence of disabilities affects not only young children's development but also the efforts of others to care and plan for them. Experts have suggested that children's disabilities may jeopardize placement stability, delay reunification, increase chances of remaining in foster care, and compound other vulnerabilities (Leslie et al., 2002; Malik, Lederman, Crowson, & Osofsky, 2002).
Identification of developmental disabilities in foster children presents a number of challenges. Co-occurring conditions complicate the identification process. Sometimes mental health issues are so urgent or compelling that developmental disabilities are not considered. Sometimes children's difficult behaviors or failure to achieve expected developmental progress are thought to be consequences of maltreatment that will resolve by removing the child from a maltreating family. Although early language impairment has been associated with subsequent behavior problems and poor social competence (Beitchman, Wilson, Brownlie, Walters, & Lancee, 1996), language problems are often undiagnosed by mental health professionals (Toppelberg & Shapiro, 2000).
IMPLICATIONS FOR INTERVENTION
Hector is a 4-year-old boy in his fifth foster placement. His current foster mother, who is committed to keeping him in her home, describes him as very active and says that he destroys toys, throws toys and clothing out of a sixth floor window, smears feces, engages in sexualized behaviors, and screams during the night. Hector was removed from his biological mother at the age of 6 months after being left alone on a bed, without supervision, while she went out for the evening. He fell off the bed onto a radiator and was badly burned. After trying unsuccessfully to heal the burns by putting water on them, the mother called 911. The police report noted that the mother seemed “mentally slow.” During the current foster placement, Hector completed a comprehensive developmental evaluation. He was found to have mild developmental delays, an attachment disorder, and posttraumatic stress disorder. Exposure to sexual abuse in a previous foster home, and a probable family history of developmental problems, were noted.
Tiffany is a 3½-year-old girl placed in kinship foster care with distant relatives at the age of 3 years after being thrown in front of a fast-moving van by her biological mother. The kinship foster mother reported that Tiffany, who had not sustained serious physical injuries, initially had trouble sleeping, and played aggressively with toys. On 2 occasions, she slapped a doll and threw it in front of a toy car. The kinship foster mother said that Tiffany now slept well and no longer engaged in aggressive play. Although she had rejected physical affection initially, she now accepted and sought it. Comprehensive evaluation 6 months after placement revealed normal intelligence and speech and language impairments. Since, to the evaluators' surprise, Tiffany did not currently exhibit social-emotional or behavioral problems, no mental health diagnosis was given.
Kyle is a 2-year-old boy with cerebral palsy and significant developmental delay. He was born prematurely at 26 weeks gestation to a mother who used alcohol and other drugs throughout her pregnancy. Kyle weighed less than 2 pounds at birth. He remained in the hospital for 3 months, then was discharged to a preadoptive foster mother. At the age of 17 months, he did not sit, crawl, stand, or walk, but was interactive and interested in other people. Developmental assessments revealed cognitive, motor, and communication skills at a 4-month level. Recommended services were for a center-based early intervention program, physical therapy, and assistance with feeding and positioning.
Hector, Tiffany, and Kyle are representative of young children in foster care. Each has different needs and will follow a different developmental trajectory. Intervention for Kyle will be intensive and lifelong. His preadoptive foster mother will need to know that intervention and supports will help Kyle optimize his potential, but will not “cure” his problems. Hector has very serious behavior problems, requiring therapeutic services (including a therapeutic preschool if available), developmental services addressing delays, and ongoing guidance and support for his foster mother. Tiffany is doing better than anyone would have predicted. She needs speech language therapy at the present time, and may or may not need psychotherapeutic services in the future. Her progress should be carefully monitored, but at the present time she can attend a community preschool. In her case, sources of resilience (normal intelligence, emerging attachment to an emotionally stable and nurturing kinship foster mother) are strengths that can be capitalized upon in intervention.
Identifying child and family needs
Standards for provision of healthcare services were developed in 1987 and 1988 by the Child Welfare League of America and the American Academy of Pediatrics Committee on Early Childhood, Adoption, and Foster Care, and have subsequently been revised by the committee (American Academy of Pediatrics, 1994, 2000). Currently, the committee recommends assessment, within 30 days of placement, of gross motor, fine motor, cognitive, speech and language, self-help, emotional well-being, and coping skills, as well as the child's behavior and relationships to other people, and the adequacy of the caregiver's parenting skills (American Academy of Pediatrics, 2000). The committee specifies that assessments should be culturally appropriate, sensitive to the child's comfort, and consistent with current child welfare standards. They should prioritize early intervention, use standardized procedures and age-appropriate instruments, explore interactive effects of developmental problems, and collect additional information over time. Useful guidelines for implementation of the standards are available in a report published by the Task Force on Health Care for Children in Foster Care of the American Academy of Pediatrics for District II, New York State (Task Force, 2001).
Unfortunately, these assessment standards have not been universally implemented. A national study of child welfare agency policies in 36 states found that more than 40% of the sampling units had no policy to identify children with mental health and/or developmental problems (Leslie et al., 2003).
Multiple service systems are often involved in the initial assessment of foster children: health, child welfare, education, and family court. The process goes most smoothly when there is collaboration across systems (Malik et al., 2002; Silver et al., 1999; Simms, 1989).
Assessment should be an ongoing process. Guidelines for foster children recommend monitoring and assessment at 6-month intervals for children younger than 6 years (American Academy of Pediatrics, 1994, 2000; Task Force, 2001). Children's functioning can change over time. Sometimes children show improvement by being removed from the adverse circumstances that led to foster placement. Other children fail to show progress or deteriorate (particularly in their behavior) during foster placement. Identification of strengths and sources of resilience, as well as problems, should be part of ongoing, as well as initial, assessment.
SUGGESTIONS FOR INTERVENTION
For a child who has been removed from his or her biological parent(s), the most urgent intervention need is a stable out-of-home placement with an adult (kinship or nonrelative foster parent) who can provide physical care and emotional support. Foster placement itself, thus, constitutes an important intervention (Clyman, Harden, & Little, 2002; Horwitz, Balestracci, & Simms, 2001; Klee et al., 1997, Ruff, Blank, & Barnett, 1990). Once adequate placement has been achieved, children's medical, mental health, and developmental needs can be addressed.
As increasing numbers of young children have entered foster care, a number of model programs have been developed to meet their unique needs. Features of intervention models include engagement of foster parents as therapeutic agents (Fisher, Gunnar, Chamberlain, & Reid, 2000); a combination of case management, behavioral treatment, and support and education groups for foster parents (Heller, Smyke, & Boris, 2002); and family-centered emphasis, including all foster family members (Klee et al., 1997). In a home-based intervention program, foster parents learn to interpret young children's behavioral signals, provide nurturance for distressed children, and enhance children's regulatory capacities (Dozier, Higley, Albus, & Nutter, 2002). Another intervention model emphasizes partnerships between biological and foster mothers (Linares, Jones, Scheiber, & Rosenberg, 1999). Maluccio and Ainsworth (2003) describe a number of programs that target substance abuse as a primary focus of intervention for biological parents.
Intervention for medical problems
Because of a lack of information regarding children's complex and highly specialized medical conditions, foster parents are often left without the background, knowledge, and resources to care for them. An essential component of intervention is to obtain medical records for the children. This should be done as they enter care or within 2 weeks of placement. The foster care agency and foster parents need to know about previous medical problems and prior surgery so that appropriate treatment and follow-up can be provided. Relevant information can be obtained through communication with biological family members, and from the previous source of routine pediatric care or the hospital of birth or prior surgery.
Young children in foster care typically have multiple chronic medical problems. In addition to routine well-child healthcare, immunizations and the treatment of acute illnesses, they require the specialized care of physicians with expertise in the care of children in foster care. This comprehensive treatment approach is best carried out in a “medical home.” Ideally, this medical setting can remain a constant even in the event of changes in foster placement. The medical home should have relationships with a team of medical specialists and an affiliation with a hospital to address and clarify all of the child's medical needs. The center should be in a position to coordinate care with developmental, mental health, child welfare, and judicial systems. Over time, the treatment team can forge a relationship with the child, foster parents, and biological parents who resume caregiving for their children. The medical home can fill in the blanks in the medical history that will make for an informed, individualized treatment plan for each child in foster care.
Intervention for mental health problems
The most critical intervention for the prevention or treatment of mental health problems in young children in foster care is the prevention of multiple changes in caregivers. Multiple disruptions in placement have been associated with the most problematic outcomes for children in foster care (Newton, Litrownik, & Landsverk, 2000). This is not within the purview of the mental health provider alone, but must be a concerted effort of all child development specialists, child welfare, and legal staff working collaboratively on behalf of each individual child to solve problems that threaten the stability of a placement. This is facilitated by the frank acknowledgement of, and preparation of foster parents for the regulatory disorders, attachment problems, and/or symptoms of trauma that often present in young children in foster care, and the provision of adequate support services to the foster parent(s).
The relationship between the foster parent and child must be considered a primary component of the therapeutic plan. Attachment between foster parent and child should not be discouraged; on the contrary, it should be facilitated and promoted as a primary vehicle for healing the child with symptoms of emotional distress. The provision of developmental therapies, including speech/language therapy for language delays, and occupational therapy for regulatory problems, often help the child become a better interactive partner. However, specific dyadic support for the relationship between the foster parent and child is a critical component of a treatment plan. This can occur in multiple settings, including early intervention programs, mental health clinics, or specialized intervention programs for children in foster care. It should include counseling and support to help foster parents maintain a nurturing stance with children whose behaviors might otherwise discourage attempts at nurturance, and guidance on caregiving strategies that promote the regulatory capacities of the child (Dozier, Dozier, et al., 2002). Guidance on the positive management of behaviors such as tantrums, aggression, hyperactivity, and self-injurious and sexual behaviors has been found to be an important component of effective intervention when it occurs early in a foster placement (Fisher, Gunner, Chamberlain, & Reid, 2000).
Psychotherapeutic services may be indicated for a young child who has had serious trauma, including sexual abuse, or exposure to domestic violence. While these services may be offered directly to the child using play therapy techniques, they should also include a parent component so that the child's caregiver develops comfort and skill in addressing children's symptoms and recollections of the traumatic event.
Behavior problems are often exacerbated after children's visits with their biological parents. This is because the visits reactivate memories of traumatic events, of the separation from parents and family, or both. Programs that provide visit coaching for biological parents aim to help parents interact with their child in ways that promote their positive relationship, and diminish parent behaviors or conversation with the child that exacerbate the child's anxiety or distress (Beyer, 1999). Expedient permanency planning is an important intervention for reducing the child's anxiety and promoting a sense of security. Dyadic therapy for the child and biological parent, to assist the parent in learning and practicing new parenting skills, can hasten reunification. When reunification with a biological parent, or other placement change occurs, it is sometimes possible to maintain contact with a foster parent, who serves as a member of the child's “extended family” (Kates, Johnson, Rader, & Strieder, 1991). Telephone calls, visits, and holiday gifts reduce the child's feelings of abandonment by biological parents and/or previous foster parents.
Intervention for developmental disabilities
Young children with documented delays and disabilities are entitled to receive publicly funded early intervention and preschool special education services. Services can include developmental therapies (occupational, physical, and speech language therapy); special instruction for the child; psychological services (play therapy and/or counseling in an educational setting); nutrition services; assistive technology; services for children with hearing or vision impairments; and applied behavior analysis or other intervention for children with autism spectrum disorders. Service availability varies across regions and school districts. Expectations about what developmental services can accomplish should be realistic, with the understanding that more services, or greater service intensities, are not necessarily better for the child.
Parent training and support are an important component of intervention for any child with a developmental disability. Learning about early childhood development, characteristics of specific disabilities and other special needs, child management approaches, and community resources enables parents to support their children in ways beneficial to development. Meeting with other parents to share experiences and ideas can reduce frustration and isolation.
Parents who anticipate future responsibility for a child need to know what a child's disability means for future functioning, and the kinds of supports that will be required in the future. The child welfare system often lacks legal mandates or funding for postadoption or post-reunification involvement with a child and family. Although early childhood professionals may lack specific child welfare expertise, they can help parents track children's developmental progress and response to intervention. This ongoing process thus becomes an avenue of parent training and support.
Barriers to implementation
Characteristics of foster families affect service implementation. The age of the foster parent and number of children in the home can reduce time and energy available to address a child's complex needs. There is often inadequate monitoring and support for nonrelative families, and even less monitoring of kinship homes (American Academy of Pediatrics, 2000; Clyman et al., 2002; Ehrle, Geen, & Clark, 2001; Gebel, 1996; Rosenfeld et al., 1997). This can jeopardize implementation of services as well as child safety. Large caseloads, inexperienced caseworkers, and frequent staff turnover in child welfare agencies contribute to inadequate monitoring.
Placement changes (placement of the child with another foster family, reunification with the biological family, reentry following unsuccessful reunification) disrupt service continuity. Medical information does not always follow the child to a new placement. Being moved to a different geographic area can mean a loss of services, as well as loss of attachment figures.
Other barriers to service implementation include inadequate resources and personnel, problems financing some kinds of services through managed care or other funding sources, and difficulties with access, including transportation. Service fragmentation occurs when services are provided by several systems, and there is often a lack of coordination and communication across systems. Confidentiality guidelines restrict exchanges of information about a particular child. Early childhood professionals may have to assume advocacy roles or spend extra time and effort overcoming barriers as they serve children and families.
Young children in foster care have complex medical, mental health, and developmental needs. Families experience multiple stressors and problems, service systems do not function perfectly, resources are not always available, and placement stability and permanence are not always ensured. Adequate care for children in foster care must begin with careful identification of risk factors, and thorough medical and developmental assessment of the child, with a strong focus on the child's social-emotional development. There should be a coordinated, individualized plan of medical, mental health, and developmental interventions for the child and supports for the foster parents. If reunification with biological parents is a goal, substantial efforts must be made to include them in the assessment and intervention plans, to assess strengths and vulnerabilities in their parenting competencies, and to ensure that adequate family supports are provided upon reunification. Minimizing attachment disruptions should be the highest priority for all involved with young children in foster care. While this is critical for the child's emotional and behavioral health, it also facilitates follow-through for medical and developmental problems. Each professional working with a child in foster care should have the child's specific risk factors in mind and should actively work with foster care staff to develop and implement a comprehensive intervention plan. A collaborative problem-solving approach involving educators, healthcare providers, child development specialists, child welfare staff, and court personnel will optimize developmental outcomes for young children in foster care.
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