Rudolph's Pediatrics, 22nd Ed.

CHAPTER 20. Foster Care and Adoption

Brad D. Berman and Carol Cohen Weitzman

Raising a child outside the child’s biological family of origin, as in foster care or adoption, presents a unique set of psychosocial challenges involving an interplay between transition and adaptation. The child must contend with separation from and possible reunification with the birth parent, adjustments to 1 or more families, and changes in physical environment, social support, and care providers. The foster or adoptive parents are challenged with helping the child integrate into a new family, taking into account the child’s previous experiences, and facing the possibility of further transitions in the future. The child’s and family’s success in adapting to these changes in care are influenced by a complex interaction between innate, individual capabilities and external resources. Nowhere is the traditional role of the pediatric provider more important in providing continuity of care, family guidance, and support for the physical, neurodevelopmental, and emotional needs of the child and family.

EPIDEMIOLOGY AND DEFINITIONS

FOSTER CARE

Approximately 500,000 children are in foster care on any given day with about 800,000 children being served by the foster care system in a year.1 In contrast to the early years of foster care when foster placement often resulted because of illness or death of parents or extreme poverty, approximately 70% of children today are placed because of parental abuse and/or neglect; more than 80% of children who enter foster care have a parent who abuses drugs or alcohol.

Children enter foster care for a variety of reasons, including the negative impact of acute and chronic family stressors, abandonment, parental inability to care for a child, homelessness, parental substance abuse, and increasingly, child neglect and/or physical and sexual abuse. Foster care is intended to be a temporary legal arrangement in which the child is protected and nurtured while supportive services are provided to the biological parent(s) to achieve family reunification.

ADOPTION

As of 2004, an estimated 1.6 million children under 18 years of age lived with adoptive parents and approximately 2.5% of US families had an adopted child. Approximately 127,000 children are adopted in the United States each year. The percentage of all adoptions by type is represented in Figure 20-1. Public agency and intercountry adoptions have grown significantly and now account for more than half of all adoptions. Approximately 10% of all adoptions are voluntarily relinquished infant adoptions. Increasing numbers of children are being adopted by transracial, transcultural, single-parent, and same-sex couples.2 Slightly more girls than boys are adopted. The trend toward international adoption has also risen steadily with approximately 20,000 children having been adopted from foreign countries in 2006.3Currently, the largest representation is from China, Guatemala, South Korea, Russia, and Ethiopia. The majority of children adopted internationally are under age 4 years, often under age 1, and female.

FIGURE 20-1. Percentage of US adoptions by type. (Freely reproduced and distributed with permission from the Child Welfare Information Gateway.)

The typology of adoption has expanded from the traditional closed adoption, in which there is little ongoing communication between the birth parents and adoptive parents, to include open adoption, in which there is a greater sharing of information. In an open adoption, which is seen more commonly in domestic infant adoptions, the birth parents usually meet the adoptive parents and agree on future communication and contacts between them and the child.4,5

FOSTER CARE

CHARACTERISTICS OF CHILDREN PLACED IN OUT-OF-HOME CARE

Children in foster care suffer from high rates of medical, developmental, and mental health problems (see Table 20-1) that have often developed prior to placement. Between 44% and 82% of children in foster care are believed to have a chronic medical condition; children under 2 have the highest prevalence.6 At least 60% of preschool children in foster care have some type of developmental delay or disability. Up to 80% of children entering foster care have a significant mental health problem as compared with 16% to 22% in the general population.1,7

Neuromaturational lags, mild to moderate developmental delays, and speech or language disorders are frequent. As a group, children in foster care often function in the low-average range of cognitive abilities, and they are over-represented in grade retention, school failure, and need for special education services.8 There is a significant need in this population for both inpatient and outpatient mental health services. Common diagnostic comorbidities include adjustment reactions, attention deficit hyperactivity disorder, oppositional defiant disorders, and stress/anxiety disorders. However, some children show improvement in school attendance and academic growth when they are placed in a supportive foster home environment.

Table 20-1. Common Medical and Mental Health or Developmental Problems Seen in Children in Foster Care

Medical problems

Growth failure and failure to thrive

Consequences of prematurity

Microcephaly

Recurrent otitis media

Asthma

Anemia

Lead poisoning

Dental caries and poor dentition

Eczema

Sickle cell anemia

Sexually transmitted disease

Occult fractures

Mental health or developmental problems

Developmental delay

Learning disability

Borderline intelligence/cognitive impairment

Attention deficit hyperactivity disorder

Depression or bipolar disorder

Conduct disorder

Anxiety disorder

Oppositional defiant disorder of other disruptive behavior disorder

Posttraumatic stress disorder

CHALLENGES TO ADJUSTMENT TO FOSTER CARE

Children

Transition to care can often exacerbate underlying problems for children due to the abrupt and traumatic separation from their biological families. Young children may blame themselves for these events and may resist developing a relationship with their foster parents out of a sense of loyalty to their biological parent. Older children may experience more feelings of anger. Children who have experienced abuse and neglect are less likely to have a secure attachment with their biological parents and are less likely to view caregivers as consistently available and nurturing. Because of this attachment insecurity, foster children respond to foster parents with dysfunctional patterns, causing the foster parent to withdraw at times from the relationship or even inflict further abuse and maltreatment. Anywhere between 12% and 25% of children are maltreated in their foster homes.9 Common behaviors seen in children placed in foster care are listed in Table 20-2.

Table 20-2. Common Behaviors Seen after Placement

Sleep disturbances

Difficulty falling asleep

Frequent awakenings

Nightmares

Reluctance to sleep alone

Eating disturbances

Overeating

Poor appetite regulation

Hoarding of food

Poor appetite

Food refusal

Developmental regression

Loss of toileting skills

Regression in language, attention and adaptive skills

Mood lability or instability

Temper tantrums

Irritability

Impulsivity

Apathy and withdrawal

Hypervigilance and exaggerated fear response

Indiscriminate sociability

Self-stimulating behaviors

Excessive masturbation

Rocking

Repetitive movements

Aggression

Biological Parents

Biological parents experience a traumatic separation and loss after the child’s placement even when it occurs as a result of abuse or neglect. Removal often occurs in the acute setting of an abusive event and the co-occurrence of substance abuse and violence, which heightens the emotional tension and chaos surrounding the removal. Biological parents often face many stressors, and they can experience complex feelings of grief, remorse, inadequacy, powerlessness, guilt, and resentment. Many of these families distrust and fear authority figures such as health professionals and child protective workers, and these feelings may interfere with taking appropriate steps to regain custody of their children. The removal of the child from the home may motivate some families to alter current parenting practices and to obtain help. About half of all children in foster care are returned to their biological families within the first 6 months after their initial removal. For some families, however, their longstanding dysfunctional patterns are entrenched and may interfere with compliance with visitation and permanency planning.

Foster Parents

In recent years, there has been a greater emphasis on placing children with extended family members, often referred to as kinship care, with a more than 300% increase in children placed in kinship care. This type of care is felt to be more culturally appropriate and to maintain stronger ties to family members in an effort to minimize the trauma of separation for the child. There is great variability in caregivers who provide nonrelative care, but these families tend to be married, middle or lower income, and religious. Approximately 50% of foster parents, however, have been shown to have a high school diploma or less.9Only a very small number of foster families receive specialized training, and even well-educated families often have limited knowledge of child behavior and development, particularly the care of traumatized or abused children. Foster parents often receive limited information about the child who is placed in their care. They may feel unsupported and ill equipped to care for highly challenging and vulnerable children.

OUTCOMES

Approximately 10% of children in foster care remain in the child welfare system for a number of years, while approximately 50% of children return to their biological families within 6 months of placement. The average length of stay in foster care has decreased over the years to about 2 years due to efforts to develop permanency plans quickly, to use kinship care more frequently, and to enhance efforts to promote family reunification. The greatest predictors of length of stay in foster care are the biological families’ cooperation with reunification plans, with minority and older children remaining in care longer.1Children experiencing at least 1 placement change tend to be adolescents and those children with behavior problems, specifically defiant and externalizing behaviors.10 These children can be expected to experience multiple placements, with about 50% experiencing more than 1 and 25% having 3 or more placements. These multiple shifts exacerbate children’s feelings of rejection, poor self-esteem, and uncertainty for their future and often can cause children to relive the initial trauma of separation.

Despite the significantly higher rates of mental health, medical, and developmental problems for children in foster care, it has been shown that children in foster care show improvements in their levels of conduct disorder behaviors, hyperactivity, and emotional stability and better school attendance and performance. Children who displayed long-term healthy social adjustment and well-being after placement in foster care reported (1) the presence of a lasting and important relationship with at least one parental figure, (2) the ability to maintain contact with the biological families, (3) that the foster families were accepting and engaged in a collaborative relationship with the biological families, and (4) that they were made to feel like part of the family.9,11

COMMON ISSUES

Two important issues that need to be negotiated for children and foster and biological families are visitation and permanency planning. Visitation can be a difficult aspect of foster care for all involved. Biological parents may not show for visits due to poor organizational abilities; barriers such as transportation, guilt, ambivalence, fear of criminal punishment, and anger; and resistance toward supervision by a child welfare worker. Ambivalence toward their child, their role as a parent, and the child welfare system may cause biological families to act in inconsistent and unpredictable ways, such as accepting then refusing help. Some parents may consciously or unconsciously sabotage permanency planning by maintaining enough contact with the child to prevent termination of their rights while not consistently working toward reunification.

When biological parents do not show for visits, children may experience feelings of rejection, unworthiness, and further abandonment, and they may relive earlier traumas. Visitations themselves may stimulate feelings of fear and anxiety in children that may compete with their feelings of grief, loss, and love for their biological parents. Children’s responses to these stressors are often misdirected toward the foster parents, who also may be struggling with their feelings of anger and ambivalence toward the biological parents. Foster parents also report feeling excluded from important decisions surrounding visitation and permanency planning. This triad of the child, foster parents, and biological parents can become entangled in shifting alliances and conflicting loyalties and may threaten the ability of each party to maintain the best interest of the child.

ADOPTION

Adoptive families represent a unique group. The prospective adopted parents must go through the effort and expense of working with an adoption agency to fulfill the legal requirements of both the United States and the child’s country of origin in the case of an international adoption and of traveling to that country to receive the child, commonly with only scant or inaccurate information about the child, the child’s family history, and the child’s health.

The core participants in the adoption process—the child, birth parents, and adoptive parents—are called the adoption triad.12 Each member of the adoption triad must adjust to the transition of the child moving from the care of one family to the care of another. The birth mother may experience a sense of loss and unresolved grief long after the adoption process ends. The adopted child must blend life experiences and feelings toward the adoptive family with the reality of a birth mother who resides outside the family. Confusion over identity, fantasies about the birth parent and her reasons for relinquishing the child, and feelings of rejection all may arise and influence the child’s sense of belonging and self-esteem. An open and accepting family attitude toward adoption has been shown to be predictive of a child’s positive adjustment to these psychological issues.

CHARACTERISTICS OF INTERNATIONAL ADOPTIVE FAMILIES

Adoptive Parents

Parents of international adoptees tend to be white, married, well educated, and economically stable. Some of these characteristics, such as age and marital status, may be requirements by the foreign country, and the high cost of international adoption accounts for the higher socioeconomic status among this population. The decision to adopt a child from another country is often the culmination of a history of failed pregnancies, loss of fertility, and loss of the imagined child. Adoptive parents may be reluctant to express the complex feelings associated with the decision to adopt because of feelings of guilt, inadequacy, and uncertainty. Adoptive families frequently get mixed messages from places such as schools, early intervention programs, and health care providers that may over-pathologize the behaviors and attitudes of the child or may fail to recognize the needs of the child. Pediatricians, too, sometimes underreact or overreact to the child’s developmental delays and behavior problems. They may either intervene or become alarmed prematurely or, conversely, wait too long to refer children for services with the belief that they simply need more time to catch up.

Internationally Adopted Children

While the internationally adopted child shares many similarities with the child in foster care, there are a few important distinctions. Often, the child’s history prior to adoption is not well known or is ambiguous or incorrect. Similar to children in foster care, many international adoptees have experienced early instability in their caregiving environment; multiple transitions, losses, and traumas; and early adversity and deprivation prior to adoption. More than 50% of adoptees have spent a portion of their lives in institutional care. The quality of care in these settings is highly variable: Child ratio, nutrition, and health care may be inadequate, and children are exposed to a high turnover of caregivers who often have limited training in child development. Some international adoptees have experienced abuse and neglect in the homes of their biological family, although this is rarely reported on the records that adoptive parents receive. These children may also have sustained some neurobiological insult as a result of poor prenatal care and nutrition and prenatal substance and alcohol abuse, with a high prevalence of alcohol abuse in Eastern Europe. Acute and chronic medical problems are common and include infections, such as human immunodeficiency virus, hepatitis, and tuberculosis; inadequate immunizations; developmental delays; speech and language disorders; and disrupted emotional development and behavior, including abnormal stress responses and attachment disorders. These risk factors place these children, similar to children in foster care, at higher risk for medical, behavioral, developmental, and mental health issues.13Compounding the changes they must cope with, international adoptees also face the loss of culture and their family of origin, and they must deal with complex issues of acculturation to a strange country, home, and language.

RULES AND REGULATIONS

The Department of Homeland Security and the US Department of State have outlined steps to be taken by prospective adoptive parents. A “home study” must be completed that involves at least one home visit and is designed to determine the suitability of the prospective parents. During this visit, the prospective parents’ physical, mental, and emotional capabilities are assessed, as are family demographics, financial resources, criminal history, and any history of abuse or violence.

Safeguarding the rights of children has been an important aspect of international adoption, and controversy exists as to whether international adoption is beneficial to children. The United Nations Convention on the Rights of the Child (UNCRC) emphasized “the right of the child to preserve his or her identity including nationality, name and family relations.”14 The UNCRC stressed that international adoption should be viewed as the last option except institutional care after all efforts to place a child with existing family members or within their community have been exhausted.

The Hague Convention on Protection of Children and Cooperation in Respect of Intercountry Adoption, on the other hand, was drafted in 1993 to recognize the legitimacy of international adoption and establish a set of minimum requirements and procedures to ensure that children are not exploited, trafficked, abducted, or sold. The Hague Convention was ratified by the United States in 2007 and will be implemented in 2008. As a result, the US Department of State is the US Central Authority for adoption. Many countries where children are commonly adopted are still non-Hague countries.

OUTCOMES

Adopted children show somewhat higher rates of neurodevelopmental and psychological morbidity, especially early in childhood. Adopted children are overrepresented among those with learning disabilities, with an estimated prevalence of school problems 3 to 4 times national norms. These children represent 5% of children seen in outpatient mental health settings and 10% to 15% of children in inpatient mental health facilities.13,15 Externalizing behaviors such as oppositional defiant and conduct disorders, reactive attachment disorders, and attention deficit hyperactivity disorder occur more frequently, as does substance abuse. However, most adopted individuals perceive their experiences positively and mature as healthy, normal children with successes and failures similar to those of their nonadopted peers. Recent reports suggest that adoptees have self-esteem similar to that of their nonadopted peers.16 The longer children have lived in their adoptive homes, the fewer behavioral problems are reported. Age at adoption, which is often a proxy for length of institutional care, is the best predictor of mental health, developmental, and learning problems.

Most adoptions are final. The rates, however, of adoption disruption (terminating an adoption before it is legally finalized) and dissolution (terminating an adoption after it is legally finalized) may be as high as 10%. Older children, children with a history of multiple placements, longer duration of time spent in foster care, and significant behavioral and mental health needs are at greater risk for disruption and dissolution.

COMMON ISSUES

As greater numbers of children are living in adoptive homes, adoptive families have become increasingly open and interested in discussing adoption and adapting some of their child’s original cultural practices into their home. Parents sometimes feel unsure about when and how to discuss adoption with their children. Discussing adoption with children can begin from the moment they enter their adoptive home and particularly when children become curious and ask questions about themselves and their background. However, it is not until children are ages 5 to 7 that they can begin to understand cognitively the difference between an adoptive parent and a birth parent. Feelings of adoption-related loss may certainly emerge by this time. From 8 to 11 years, questions regarding their permanence within the adoptive family may arise, possibly mixed with fantasies of being reclaimed by a birth parent. During early to mid adolescence, the young teen struggles to consolidate different notions of self with beginning interest about information on the birth family and heritable traits. By mid to late adolescence, there is a clearer understanding of the emotional and legal permanence of the adoption.17 At this time, adopted children also may begin to seek contact with their birth mother or other members of the birth family. There are many books and resources available to aid parents in discussing adoption with their children, and it is important that parents respond with answers that are appropriate to a child’s developmental understanding of adoption and identity formation.18

HEALTH CARE PROVIDER’S ROLE

The pediatrician occupies an ideal position to assist in the foster or adoptive child’s adaptation to a new family by (1) providing thorough health supervision, (2) assisting families in coordination of services and providing professional advocacy, and (3) serving as a counselor to the child and family.1,4,19 (See Table 20-3.)

Table 20-3. Supportive Role of the Pediatrician in the Care of the Foster or Adoptive Child

Prior to adoption

Preview information on the child (eg, medical records, prenatal information, family history, videotape of child)

Advise on supplies to take to pick up the child (eg, medicines, formula)

Advise on vaccines, medicines for parents traveling to a foreign country

Plan for evaluation of the child upon return

Refer family to support group for domestic or international adoption

Anticipatory guidance for new parents

Medical evaluation

Immediate visit (first week)

Obtain available records, including prenatal and birth history, growth curves, immunization records, hospitalizations, results of health screening (eg, lead, anemia), and medications

Evaluate/treat acute illnesses

Measure baseline growth; check nutritional status of the child

For the foster child, become familiar with key personnel, including caseworkers and attorneys

Address any immediate concerns of the family

Assess immediate family coping and adjustment

Comprehensive examination (4–6 weeks)

Complete physical examination: Check for congenital anomalies, chronic conditions, nutritional disorders

Screen vision, hearing, dental

Update immunizations

Recheck newborn screening if child is under 3 months old

Screening medical tests when appropriate to include complete blood count, lead, iron (look for hemoglobinopathies), urinalysis, tuberculosis (purified protein derivative), stool ova and parasites, hepatitis B and C, human immunodeficiency virus, syphilis, malaria (if appropriate)

Developmental evaluation: gross and fine motor, communication, adaptive and cognitive skills, initial behavior and coping responses

Developmental screen for language, autistic spectrum disorders, learning and attentional difficulties

Anticipatory guidance: refer to support groups, appropriate literature

Periodic surveillance

Examine children in sensitive and compassionate settings (eg, it may be stressful to child if both biological and foster parents are present at a visit)

Well-child care, complete and update immunization schedules

Monitor own emotional responses to biological and foster parents and child; avoid being pulled into adversarial relationships or taking sides

Monitor growth, nutrition

Check for late signs of infection

Close developmental and behavioral surveillance (at any age)

Episodic developmental screening using standardized instruments to detect developmental and/or behavioral problems

Counsel or refer for developmental or behavioral problems

Monitor events related to visitation and permanency planning for the child in foster care and communicate episodically with caseworkers

Advocate for the rights and needs for adoptive and foster children in the educational and legal sectors

The health professional also is in a unique position to provide a global view of the child’s strengths and needs within the context of the family, thus helping to facilitate planning for individual or family interventions when necessary. The pediatric provider is also a key resource for families in advocating for appropriate educational interventions. Such a role requires a working familiarity with local educational, social, legal, and mental health resources for children.

Physicians may find themselves in the role of counseling the adoptive or foster family, the child, and the biological parents. Feelings of guilt, confusion, and frustration require an empathic ear. An understanding, open, and neutralhealth professional can be a valuable resource for children as questions of self-identity arise in the middle-school years. Clinicians also may serve as a sounding board to prospective parents about decisions regarding foster or adoptive care. Families often need guidance as they try to understand their child’s development and behavior within the context of foster care and adoption and sometimes need assistance. At times, appropriate referral to a mental health professional will be necessary. The pediatric health care provider thus occupies a central role in monitoring the well-being of the child and family and of supporting their adaptation to the sequence of transitions experienced in foster care and adoption.