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Chapter 31: Child Psychiatry
31.19b Adoption and Foster Care
According to the U.S. Department of Health and Human Ser-
vices, 408,425 children and adolescents were in foster care in
the United States in 2010. Most children entering foster care
have experienced multiple traumatic events including neglect,
or abuse, which are typically the precipitant for their removal
from their biological parents. One study estimated that 26 per-
cent of children in the United States will experience a traumatic
event by the age of 4 years. Over the last decade, specifically
between the years of 2000 to 2010, the number of evaluations
for suspected child maltreatment has increased by 17 percent,
according to another study.
Foster care is intended to be temporary out-of-home care,
provided by the welfare system, for children and adolescents
whose immediate families are unable to care for them. Given
the severity of the pathology of vulnerable parents; however,
care is often needed for many months and years. In 1997, Presi-
dent Clinton signed the Adoption and Safe Families Act, a law
designed to improve provisions for child safety, to decrease the
length of time that a child remains in foster care without long-
term planning, and to limit the amount of time in which a bio-
logical parent has to undergo rehabilitation to 12 months. An
additional law was added to allocate federal funds for indepen-
dent living assistance for adolescents and young adults aged 16
to 21 to assist them in transitioning to independent living.
Epidemiology and Demographics of
Foster Care
The number of children entering foster care due to maltreatment
has risen in the last decade by 19 percent. Of those children
who entered foster care, there was an increase of 60 percent in
the number who were identified as emotionally disturbed. In the
United States, one of the most common scenarios of children
being placed in foster care involves parental substance abuse,
which leads to inability of the parent to care for their chil-
dren. The National Center on Addiction and Substance Abuse
of Columbia University reported that seven of ten abused or
neglected children had parents with substance abuse. Further-
more, children in foster care were more often being raised by
a single mother prior to placement compared to children in the
community.
Minority children are overrepresented in the foster care
population. In a study utilizing birth records and child pro-
tective service (CPS), black children were more than twice
as likely to be referred due to maltreatment, be substantiated
as victims of maltreatment, and enter the foster care sys-
tem before age 5 years, compared to white children. How-
ever, low socioeconomic black children had a lower rate of
referral, substantiation, and placement in foster care than
socioeconomically similar white children. Among Latinos,
children of U.S.-born mothers were significantly more likely
to have involvement with CPS, compared to Latino children
of foreign-born mothers. However, after adjusting for socio-
economic factors, the relative risk of referral, substantiation,
and entry into the foster care system was significantly higher
for all Latino children than for white children. Approximately
38 percent of children in the foster care system are African
American, more than three times their representation in the
general population. Whites make up approximately 48 per-
cent, and Hispanics make up almost 15 percent of foster
children; 55 to 69 percent are girls, and 83.4 percent enter
foster care at a mean age of 3 years. Children placed in care
as infants are more likely to stay in care. Those younger than
5 years of age currently comprise the fastest growing segment
of the foster care population. Studies reveal that up to 62 per-
cent of foster children had prenatal drug exposure.
Needs of Foster Care Children
Children entering foster care have enormous mental health
needs; more than 80 percent of them have developmental, emo-
tional, or behavioral problems. It is estimated that up to 70%
of these children have diagnosable psychiatric disorders. In
addition, according to one study, quality of life (QOL) is sig-
nificantly poorer among children in the foster care system than
children in the general community. Children and adolescents
living in residential care rated their QOL as poorer than those
living with foster families. Up to 50 percent of foster care chil-
dren exhibit depressive symptoms, and self-reports of anxiety
problems occur in about 36 percent. QOL is adversely affected
by the presence of mental health problems, and those youth
with greater mental health difficulties rated their QOL as poorer
whether in residential facilities or foster placement. In a review
of the literature, psychiatric disorders found with increased
frequency in foster youth were attention-deficit/hyperactivity
disorder (ADHD), posttraumatic stress disorder, conduct dis-
orders, attachment disorders, substance abuse, depression, and
eating disorders.
In addition to high rates of psychiatric disorders, foster
care youth are referred to pediatric clinics more frequently due
to multiple health problems compared to community youth.
Growth abnormalities (including failure to thrive), neurologi-
cal abnormalities, neuromuscular disorders, language disor-
ders, cognitive delays, and asthma are prevalent. Health care
costs in foster care youth are six to ten times that of matched
non–foster-care peers. Among children 0 to 5 years of age,
approximately 25 percent are seriously emotionally damaged;
attachment disorders are increasingly diagnosed. Foster care
children use the full range of mental health services: outpa-
tient, acute inpatient, day treatment, partial hospitalization,
and residential treatment. Adolescents in foster care are at
increased risk for substance abuse, teenage pregnancies, and
sexually transmitted diseases, including human immunode-
ficiency virus (HIV). With public health care increasingly
adopting a managed health care system, which is designed to
limit care, grave concern exists that the provision and delivery
of services to this medically and psychiatrically vulnerable
population may be seriously compromised.
Kinship Care for Foster Children
More states are recognizing kinship care as an alternative place-
ment option and are authorizing licensing and reimbursement to
kinship caregivers who are generally female (mostly maternal
grandmothers), of low income, of low education, and of minor-
ity status. Currently, nationwide, approximately 23 percent
of African American children are in foster kinship care. It is
