Version May 2024
INTRODUCTION — Children and adolescents who spend time in foster care have been exposed to multiple adverse childhood experiences and trauma. This is also true for other children whose families are involved with the child welfare system and children living away from their parents in informal placements with relatives.
An understanding of the structure, goals, and mandates of the foster care system, as well as the unique health, mental health, developmental, and educational problems of children and adolescents in foster care, facilitates provision of appropriate comprehensive care to this vulnerable population [1,2]. In particular, health providers need to understand and be able to educate other professionals and caregivers about the impact of early childhood adversity and trauma on emotional, behavioral, and developmental health. (See "Comprehensive health care for children in foster care", section on 'Complex childhood trauma and toxic stress'.)
The epidemiology of foster care placement and an overview of the structure, goals, and mandates of the foster care system will be discussed here. The health, mental health, developmental, and educational needs of children in the foster care system are discussed separately. (See "Comprehensive health care for children in foster care".)
BACKGROUND — Involvement with child welfare usually begins when a mandated reporter or other citizen makes a report to child protective services for concerns of child abuse or neglect. Of the 4 million families reported in the United States in 2021, approximately 52 percent were investigated for child maltreatment. Of these, 16 percent (involving approximately 600,000 children) of the allegations were substantiated [3].
Whether or not allegations are founded, most families remain intact and are referred to a variety of preventive and alternative services. The Family First Prevention Services Act (FFPSA, 2018, PL-115-123) incentivizes state and local child welfare agencies to focus on family preservation through the provision of evidence-based or trauma-informed mental health, substance use, and parenting interventions unless child safety is at imminent risk.
Removal of children occurs when child protective services affirms that the child is at imminent risk of harm if they remain in the home. Child welfare has to substantiate the reasons for removal to the court system within 72 hours to keep the child in placement.
Children who are placed in foster care must be placed in the least restrictive setting that meets their needs, which is usually family foster care. This is based on the fundamental premise of child welfare that children fare best in families. Some communities place children in shelters pending availability of a family. This practice escalated during the coronavirus disease 2019 (COVID-19) pandemic when foster families were filled with existing children or declined to accept new children. Approximately one-third of children are placed with relatives or kin, while the majority are placed in nonrelative foster care. Oversight by the court and case management by child welfare continue until discharge from foster care by the court. Discharge options include reunification with a parent, guardianship by a relative, kinship placement, adoption, or emancipation at age 18 to 21 years.
Children and adolescents who are placed in foster care have usually suffered childhood trauma from a variety of accumulated adverse childhood experiences. Placement in foster care is intended to be a temporary arrangement during which the health and safety of children are protected while the birth parents are provided with services that support reunification with their children. Separation from the birth family, inconsistent visitation patterns, conflict between caregivers, and the uncertainty about one's future that is inherent in foster care may cause further distress and trauma for the child in out-of-home care.
Foster care is mandated to seek timely permanency for children in its care, either through reunification with family, placement/guardianship with relatives, or adoption. If independent living is a realistic goal for an adolescent, foster care is mandated to provide services, beginning at age 14 years, that nurture the adolescent toward independent adult living. Emancipation from foster care can begin at age 18 years, although every state now allows young adults to remain in foster care until age 21 years.
EPIDEMIOLOGY
Number of children in foster care — The exact numbers of children in foster care are difficult to determine. In the United States, approximately 391,000 resided in foster care on any given day in 2021 [4]. A study using data from the Adoption and Foster Care Analysis and Reporting System and synthetic cohort life tables (2000 through 2011) estimated that approximately 6 percent of children in the United States were placed in foster care at some point between birth and 18 years of age [5].
During the same time period, child welfare made great efforts to reduce the numbers of children, especially minoritized children, removed from their families, and annual foster care placement numbers decreased by approximately 25 percent. However, there was an increase in child abuse referrals, and the number of children and adolescents in foster care who were classified as emotionally disturbed almost doubled [6]. Although overall numbers of children in foster care declined, the greatest decline was in African American children. From 2009 to 2019, the percentages of Black children entering foster care decreased from 25 to 21 percent, while the relative percentages of White, Hispanic, and multiracial children entering foster care increased [7]. Black children represented 22 percent of all children in care in 2021 [4].
Between 2000 and 2021, the number and proportion of foster care placements attributed to parental drug use steadily increased (from 39,130 to 73,921 and 14.5 to 36.0 percent, respectively) [4,8]. This was attributed predominantly to the surge in caregiver opioid use disorder. There was also a surge in unaccompanied refugee minors in 2014 to 2016, mostly from Mexico and Central America [9]. Most states have a Safe Haven Law, which allows anonymous surrender of newborns [10].
Although no national database tracks legally surrendered or illegally abandoned newborns and infants, in a cross-sectional study from a large urban county, more than one-half of safely surrendered infants had medical issues, suggesting the need for increased monitoring and access to medical and social services [11].
Reason for placement — Almost all children and adolescents in foster care are placed involuntarily by court order for reasons of abuse or neglect, abandonment, or because they are "persons (or children) in need of supervision" (PINS or CHINS) or juvenile delinquents (JD) [12,13]. In 2021, 206,812 children were admitted to foster care [4].
Among children admitted to foster care who were maltreated in the United States during 2022, the various types of maltreatment occurred with the following frequencies [4]:
●Neglect – 63 percent
●Drug abuse of parent – 36 percent
●Caregiver inability to cope – 14 percent
●Physical abuse – 12 percent
●Inadequate housing – 9 percent
●Child behavior problems – 7 percent
●Parent incarceration – 6 percent
●Alcohol abuse by parent – 6 percent
●Abandonment – 5 percent
●Sexual abuse – 4 percent
●Other (child substance/alcohol abuse, child disability, relinquishment, parent death) – 6 percent
States that have expanded Medicaid resources have demonstrated lower rates of child maltreatment [14]. Studies have demonstrated that the Medicaid expansions resulting from the Affordable Care Act are associated with a reduction in child neglect reports and a sizable decrease in foster care admissions [15]. The benefits of Medicaid expansion are further supported by the finding that financial resources, such as family income and minimum wage rates, indirectly impact child maltreatment rates [16,17].
Less than 1 percent of children are voluntarily placed in foster care because of parent request or child complex chronic illness. Some parents continue to seek placement for children and adolescents with serious mental health or behavioral problems when parents have exhausted their health insurance benefits for their child's mental health care [18]. Birth parents who place their children voluntarily retain the right to terminate the placement at any time with written notice to the court [19].
Risk factors — Parents of children entering foster care have a high burden of mental illness, substance abuse, family violence, and impaired parenting skills [20-22]. In the National Survey of Child and Adolescent Well-Being, more than 80 percent of the birth parents/caregivers were reported to have significantly impaired parenting skills by the investigating child protective caseworker [22]. The parents' problems are often rooted in their own personal experience of childhood trauma, adversity, or loss; approximately one-third report that they were a victim of child maltreatment. The over-representation of minoritized children in foster care suggests that systemic and structural racism and discrimination may account for a proportion of removals.
Poverty is a major predictor for foster care placement [23]. There is concern that child welfare professional investigators may confuse poverty with neglect, especially when the family is of a different race/ethnicity or cultural tradition. Child welfare services have been trying to address the "disproportionalities" that exist across the spectrum of care, from reporting and investigation to removal and placement, as well as length of stay and discharge planning. Historically, other contributing factors that may also reflect systemic and structural inequities that lead to poverty, stress, health, and mental health issues have included [1,2,20,23,24]:
●Homelessness
●Parental involvement in criminal activity
●Parent severe/chronic physical illness
●Lack of social supports
●Single parent
●Parent with limited education
●Parent with cognitive impairment
●Parent substance use disorder
●Parent mental health problems
●Domestic violence
Age and sex — Approximately 37 percent of children in foster care are younger than five years of age, and another 28 percent are ages 13 to 20 years [4]. The numbers of males and females in foster care are approximately equal.
Race/ethnicity — Children of color and children from underrepresented groups are disproportionately represented [4]. Black or African American children, who account for approximately 15 percent of the general population, are overrepresented in foster care (22 percent in 2021). Despite a relatively larger reduction in the percentage of Black or African American children in care compared with other racial/ethnic groups from 2000 to 2021, concern persists that the overrepresentation of Black or African American children in foster care results from bias in decision-making during child protective investigation, with relatively more children from underrepresented groups removed from their families than White non-Hispanic children, despite similar risk factors.
Length of stay — The average length of stay in foster care is approximately 22 months [4]. Data from the Adoption and Foster Care Analysis and Reporting System indicate that 35 percent of children who exited foster care during 2021 spent <12 months in foster care, but 34 percent spent ≥24 months, and 5 percent spent ≥5 years [4].
Children of color, older children, children with many siblings, and children with significant behavioral problems or developmental disabilities are twice as likely to remain in foster care [1]. Length of stay is inversely related to the birth family's ability to meet the obligations as set out in the child welfare permanency plan. However, there is concern that families are often not provided with the support and resources necessary for them to do so.
Placement changes — In the Northwest Foster Care Alumni Study, which surveyed 479 foster care alumni at an average age of 24.2 years, the mean placement change rate was 1.4 per year [25]. The same factors that predict longer stays in foster care (children from marginalized populations, older children, children with significant developmental or behavioral problems) also predict more placement changes or greater placement instability. However, placement changes are also affected by child welfare administrative decisions, demands from the family of origin, and stressors in the foster/kinship home, such as caregiver physical illness, and by child behavior problems. Increased length of stay in foster care is an independent predictor of decreased likelihood of reunification and reduced placement stability [26]. Children in kinship care have more stable placements but longer lengths of stay [27].
OVERVIEW OF THE FOSTER CARE SYSTEM — The foster care system in the United States is complex. Caseloads are high, and worker training and education is often inadequate to the complexity of the tasks for which they are responsible [1]. The legal and regulatory framework designed to protect children and families and improve their outcomes is challenging to navigate. Courts have oversight, and there are multiple attorneys and advocates representing child welfare, parents, and children in each case. The federal government determines the patterns of funding and regulatory guidelines, whereas state agencies determine the structure and implementation of programs [1]. At the local level, the day-to-day foster care operations can be managed by private foster care agencies or public child welfare agencies, or a combination of public-private partnership. Foster care agencies, whether public or private, have five main tasks [28]:
●To establish and maintain a system of substitute care for children who have been removed from their parents.
●To help children adjust to substitute care and to monitor their progress while in the substitute care setting.
●To provide services to birth parents that will increase the likelihood of reunification. This includes visitation, which maintains and improves the parent-child relationship while protecting the child's safety.
●To make a "diligent effort" toward establishing a permanent home for children in foster/kinship care through reunification with family, placement with relatives, or adoption. (See 'Foster care legislation' below.)
●To prepare adolescents for independent adult living when reunification, adoption, kinship care, or guardianship are not possible.
Foster care legislation — Legislation provides the foundation for the regulatory framework developed by the states to manage and guide their child welfare agencies. States are sometimes sued when they fail to meet the requirements set forth in legislation, and a number of states are operating under consent decrees to redesign their systems of care to better meet the needs of children as a result of those lawsuits.
The major federal laws that regulate foster care in the United States include [29]:
●The Adoption Assistance and Child Welfare Act of 1980 – The Adoption Assistance and Child Welfare Act of 1980 (Public Law 96-272) mandated states to develop a permanency plan for each child within 18 to 24 months of entry into the foster care system [30]. This law was, in part, a response to a 1977 survey showing that more than 100,000 children had been in foster care for longer than six years without a permanent family resource identified [31].
Public Law 96-272 requires agencies to implement an accountability system to safeguard the rights of all involved parties [19,32]:
•Agencies must make "diligent efforts" to prevent placement and keep the family intact before a child is placed in foster care.
•Written case plans must document that the placement has been made in the least restrictive setting, in the child's best interests, and close to the parents' home.
•Case reviews must be conducted every six months to assess compliance with the case management plan, the appropriateness of the current plan, and a projected date for termination of foster care. Natural parents must be notified of case reviews and invited to attend.
•A dispositional court hearing must be held no later than 18 months after the child enters foster care.
●The Adoption and Safe Families Act of 1997 – The Adoption and Safe Families Act of 1997 (ASFA, PL-105-89) was a response to what was viewed at the time to be an over-emphasis on birth parents' rights to the exclusion of what was in the best interests of children (timely permanency in a family setting, whether through reunification, guardianship, or adoption). The ASFA refocused the foster care system on the rights of children to health, safety, and permanency [33]. It mandated that a permanency plan must be made no later than 12 months after the child's entry into care and that states begin termination of parental rights once a child had been in foster care for 15 of the previous 22 months as long as there was no compelling reason not to do so. It also provided increased adoption subsidies. The ASFA has become controversial because of data indicating that termination of parental rights occurred more frequently in minoritized populations.
●The Fostering Connections to Success and Increasing Adoptions Act of 2008 (PL 110-351) – This major overhaul of the child welfare system has several major provisions:
•Provides states the opportunity to extend guardianship assistance to support kinship caregivers in cases where children in foster care are unlikely to be adopted or reunify with their parents
•Requires states to make reasonable efforts to place siblings together or provide for frequent sibling visitation
•Requires states to notify adult relatives of a child within 30 days of a child's removal from their parent
•Allows states to claim federal reimbursement for foster care board subsidy for youth through 21 years of age who are in a supervised independent living setting and requires development of a transition plan within 90 days of emancipation from foster care
•Requires states to address educational stability and ensure enrollment of all school-age children in school
•Requires states to develop a plan for oversight and coordination of health care services for children in foster care, including access to a medical home, and requires states to engage pediatricians in development of such plans
●Child and Family Services Improvement and Innovation Act (PL 112-34) required, among other things:
•Each state plan for oversight and coordination of health care services for any child in foster care to include an outline of:
-The monitoring and treatment of emotional trauma associated with a child's maltreatment and removal from home
-Protocols for the appropriate use and monitoring of psychotropic medications
•Each state plan for child welfare services to describe:
-Activities to reduce the length of time children under age five are without a permanent family
-Activities to address the developmental needs of such children who receive benefits or services
●The Family First Prevention Services Act (FFPSA, PL-115-123) of 2018 emphasizes the importance of children growing up in families, maintaining children in their family of origin, and rearing children who are removed from their family in a family-like setting unless there are unique special health care needs for which a higher level of care is needed. The implementation by states of the FFPSA has lagged partly because of the COVID-19 pandemic, but also because states are struggling with developing and implementing the evidence-based or trauma-informed services necessary to support it.
The FFPSA:
•Enables states to use Title-V E foster care funds to provide families with evidence-based services to prevent family disruption, including home-based mental health and substance abuse services. Although initial services are limited to a duration of 12 months, families can receive these services more than once. This clause represents a major shift in child welfare funding priorities.
•Removes outdated income restrictions, increasing the number of families eligible for preventive services.
•Establishes the first federal guidelines for residential treatment facilities (RFTs), including evaluation of need, support for parenting education to facilitate reunification, required use of trauma-informed services, and individual and family counseling services.
The FFPSA did not address foster parent recruitment and training to correct the shortage of foster homes willing to care for children, particularly adolescents. Foster and kinship parents need more resources to support them, including temporary childcare (ie, babysitting) and respite care for children who may have greater medical or social-emotional health needs. Temporary childcare support has been demonstrated to decrease rates of foster parent burnout and stabilize foster child placements [34,35].
State implementation of shifting the emphasis to family preservation and stability as long as child safety can be assured has lagged for a number of reasons. The legislation was enacted in February 2018 with a timeline for state implementation that was extended to allow for identification of approved evidence-based or trauma-informed interventions by the United States Department of Health and Human Services, and then delayed by the COVID-19 pandemic. Some states have limited services available compared with their need. The lack of nonrelative family foster homes willing to take adolescents has made moving youth out of congregate care challenging. Finally, some states have lobbied hard against reform of the RFTs and congregate care settings. For example, California was in the process of its own congregate care reforms when the FFPSA was passed and has subsequently lobbied against implementation.
Other legislation supports empowering children in foster care to participate in social and extracurricular activities under the Reasonable and Prudent Parenting Standard (RPPS), a federal policy that is part of the Preventing Sex Trafficking and Strengthening Families Act (HR, 2014) [36]. Enabling children in foster care to participate in normalizing activities has had demonstrated positive effects in mitigating symptoms and behaviors associated with childhood trauma [37,38].
Foster care personnel — Each family involved with the foster care system is assigned a caseworker who has several tasks [1]:
●Make a "diligent effort" to help parents access a variety of educational, service, and community resources needed for them to achieve safe reunification (eg, counseling, drug rehabilitation, housing)
●Supervise the care provided by the foster parent and help to coordinate the educational, developmental, medical, and mental health services for the child
●Ensure that visitation is of a frequency and quality to maintain and support the birth parent-child relationship while ensuring the child's safety
●Support foster parents through the process of caring for the child in the uncertain world of foster care
●Document the progress of the child and family for the court
●Concurrently plan for reunification, placement with a relative, or adoption to facilitate timely permanency
The ability of caseworkers to accomplish these demanding, and sometimes conflicting, tasks is limited by lack of availability of specialized services for birth parents and children, lack of adequate and appropriate training and education, and large caseloads [1,19]. Child welfare is, however, structured so that caseworkers are closely mentored and supervised by more senior experienced personnel.
In addition to the caseworker, children in the foster care system may be appointed a law guardian (also called a "guardian ad litem"). This professional is often an attorney but may be a layperson in some states. The law guardian is designated to be the child's voice in court, although many law guardians may not have met the child before appearing in court on the child's behalf. Occasionally, the court also may appoint a special advocate (court-appointed special advocate, or CASA) who represents the interests of the child in court; the CASA is a trained volunteer, not an attorney.
The birth parents and the foster care agency also have legal representation in court.
Court is by design an adversarial process, in contrast to the movement in child welfare toward shared parenting and building relationships between foster/kinship caregivers and birth parents in the best interests of the child.
Types of placement — The site of placement is determined by the child's needs and is supposed to be in the least restrictive environment. As noted above, legislation (FFPSA) has focused on the importance of placing children in family-based care whenever possible. The options include foster care homes, kinship care homes, specialized or therapeutic foster homes, and group homes or RFTs. The optimal placement is within a well-supported family where the foster- or kinship-care parents have received training related to child development, behavior, parenting, and the impact of childhood trauma and trauma-informed parenting. (See 'Foster care legislation' above.)
●Foster care home – Foster parenting is a voluntary program that is heavily dependent upon the good intentions and abilities of altruistic laypeople. Foster parents usually are motivated by love of children, religious conviction, altruism, sense of mission, or personal need [1]. They typically are married, have raised their own children, and have middle or lower-middle incomes [1,20]. Most foster parents care for more than one child in foster care; state laws set the maximum number of children in foster homes, depending upon their ages, from four to six [1]. An unknown percentage of foster parents choose the foster-to-adopt pathway in hopes of being able to adopt children placed in their home.
Foster parents typically receive limited training and minimal continuing education. Training briefly covers child development, managing behavior problems, discipline, safety, the impact of child abuse and neglect, childhood trauma, and the foster parents' relationship with the foster care agency and birth parents. Caseworkers, who may have no more than some college education, are expected to provide ongoing support and advice but may lack expertise about child development, behavior, parenting, and the impact of childhood trauma. The annual recertification required for foster parents is less intense than the initial certification process [1].
While foster parents receive a foster care board subsidy for the care they provide, the amount of reimbursement varies from state to state. Although the board subsidy should be adjusted depending upon the age of the child and the anticipated complexity of the child's care, average basic monthly stipends for children without complex medical needs range widely [39]. The stipend is expected to cover the cost of food, shelter, personal needs, recreation, transportation, and education for the child. Some states provide an additional allowance for clothing [1]. The cost of medical care usually is paid by state Medicaid programs, which is not sufficient to provide adequate access to physical and mental health care. In most states, on average, foster parents subsidize approximately 33 percent of the true cost of caring for a foster child [39].
●Kinship care – Kinship care is a term that encompasses relatives who have become certified foster parents as well as relatives and friends who care for children placed with them by the court as a result of child protective investigation but choose not to enroll in the certification process. The largest group of children living with adults who are not their parents reside in informal kinship care, most without ever being involved with child welfare or the courts. Until the passage of Fostering Connections in 2008, states usually did not provide subsidies for kinship families who were not certified foster parents.
It is estimated that there are approximately four to eight times as many children living in informal kinship care as in foster care, and that kinship caregivers are older, poorer, and have more health problems than the average foster parent [40-42]. There has been a substantial increase in the use of kinship homes so that, in some communities, nearly one-half of the foster homes are kinship homes [24]. Overall, placement with a relative occurs in approximately 35 percent of official foster care placements [4].
Placement in kinship care is advantageous in maintaining the child's connections to the larger family of origin and is less likely to be a disruptive transition since children are likely to have had a pre-existing relationship with the kin caregiver. Kinship placements are also more stable for children over time than foster care placements, and caregivers report fewer behavioral problems than do unrelated foster caregivers [27,41,43]. However, children in kinship care are less likely to receive needed health services, have more unsupervised contact with birth parents, stay in placement longer, and have less contact with agency social workers than those in traditional foster care [29,44,45].
The American Academy of Pediatrics Council on Foster Care, Adoption, and Kinship Care states that placement of a child in kinship care be "based on a careful assessment of the needs of the child and of the ability of the kinship caregiver to meet those needs. As with all foster care placements, kinship care must be supervised adequately" [45].
●Specialized or therapeutic foster homes – Specialized or therapeutic foster homes are those in which foster parents have extra training and education and/or provide care for children with special health care needs (eg, emotional disturbances, chronic medical illness, major developmental disabilities). A few successful therapeutic foster parenting models have been developed in which foster parents receive detailed education and training and ongoing support from a mental health specialist in managing a child or teen with significant mental health problems [46,47]. Unfortunately, in most localities, the term "therapeutic" is applied more loosely, and foster parents may not receive the level of training, support, and supervision necessary to help traumatized children heal [48,49]. Some model programs exist (eg, Treatment Foster Care Oregon) [50-53]. However, the outcomes for children placed in these treatment homes have not been studied rigorously [49].
●Residential or group homes – Approximately 11 percent of children in foster care live in group homes or RFTs [4]; most of these children are ≥12 years of age [54]. In general, these "congregate care facilities" care for older children and adolescents with significant mental health or behavioral problems. Professional supervision is available on site to trained staff, and most states have detailed regulations covering health and safety. The FFPSA provides federal guidance for RFTs, the highest level of group care.
RFTs are intended to provide time-limited placement for diagnosis and treatment, but care often becomes extended for adolescents with major mental health issues [1]. Because children require a continuous, nurturing caregiver for optimal emotional and cognitive development, facilities with rotating staff may not be in their best interests. Given the lack of data regarding the impact of group care on outcomes, group care should be reserved for extreme situations. The FFPSA requires RTFs to re-evaluate a child's need for services every six months.
The FFPSA did not address foster parent recruitment and training to correct the shortage of foster homes willing to care for adolescents. The shortage of foster parents, especially in large urban settings, has led to an increased use of "shelters" (ie, short-term, emergency housing pending longer term placement) when children are removed from their parents. Even with state regulations limiting the duration of such placements, agencies are often forced to maintain children in these groups care facilities for longer periods as they search for a family home setting.
Birth parents — Birth parents retain legal guardianship of their children and are expected to cooperate with the child welfare agency in designing and implementing the service plan that will permit reunification with their children [24]. Most birth parents, however, have multiple challenges, including their own mental health and/or substance abuse issues, and their own history of trauma in both childhood and adulthood. At least 10 percent of birth parents are cognitively delayed, and few experienced a normal, predictable upbringing themselves. Approximately 33 percent of birth parents admit to a history of childhood abuse and neglect [55].
Many birth parents require a range of services (mental health, substance abuse treatment, housing, job training, parenting skills training), not all of which may be available in their communities or in appropriate settings. Parenting skills training, in particular, often occurs in a classroom, in isolation from their children, when one-to-one mentoring during visitation may be a beneficial added intervention [56].
Visitation — Visitation is a mandatory component of foster care and is the single best predictor of reunification [57]. Visits are intended to maintain and improve the quality of the child-parent relationship. They provide the child welfare agency with an opportunity to monitor parent compliance with the case management plan and to evaluate parent-child interactions [45]. Visits also provide an opportunity to offer trauma-informed mental health services, such as parent-child interaction therapy or child-parent psychotherapy, which have been associated with improved reunification outcomes [58].
However, visitation is stressful for all involved parties; children may react to parental visits with an increase in behavioral problems even when the visits are going well and are desirable to the child [19,24,59]. Children in foster care worry about their parents, and the separation at the end of each visit may evoke intense fear in the child. Conflict between the foster parent and birth parent, differences in parenting styles, erratic parental compliance, and unrealistic expectations regarding the quality or outcome of the visits may create confusion, anxiety, or anger in children. Occasionally, birth parents engage in subtle or provocative behaviors that remind children of prior trauma.
Visitation supervisors must be alert to safety issues, including emotional safety issues, for children. Foster parents can help the children in their care by preparing them for visits with their birth parent(s) and assuring them that they will be there to greet them after the visit [27]. Rescheduling visits that significantly disrupt the child's routines can improve the quality of the visits. Visits that are scheduled during a child's usual nap-time, that conflict with a child or teen's favorite activity, or disrupt the school day should be rescheduled.
Involving the child's therapist in the visits, changing the setting, or increasing the level of supervision may be required [19]. In rare circumstances, suspension of visits with parents may be necessary (eg, if the parent behaves in ways that traumatize the child, or if there is no realistic chance that the parent will be able to care for the child in the future) [19].
Although the preferred practice is for agencies to hire and train child welfare professionals to support birth parents and children through visitation, some agencies rely on foster or kinship caregivers to monitor or supervise visits if child welfare professionals are not available. Caregivers may identify concerns about the behavior of the birth parent but feel constrained in reporting because of concern about the impact on their relationship with the birth parent or that the birth parent will request a placement change.
Termination of parental rights — The birth parents may lose their parental rights through voluntary surrender or through a legal process called "termination of parental rights."
Voluntary surrender of parental rights is infrequent. However, occasionally a birth parent makes the difficult decision that adoption is in the best interest of their child and voluntarily surrenders their rights. Voluntary surrender is often accompanied by an "open adoption" in which the child may maintain some ongoing contact with the birth parent.
More often, involuntary termination of parental rights occurs by court order [1]. Parental rights may be involuntarily terminated for a number of reasons [19]:
●Birth parent(s) have made little progress in improving the home situation despite "diligent efforts" on the part of the case worker
●Birth parent(s) have not visited regularly for the previous six months
●Birth parent(s) fail to "substantially maintain contact with the child or to plan for their future, although physically and financially able to do so"
●Birth parent(s) are unable to provide adequate and safe care by reason of mental illness, intellectual disability, or other impairment
OUTCOMES OF FOSTER CARE — The outcomes of foster care placement are as follows [1,20]:
●The majority of children are returned to a parent or relative (approximately 47 and 6 percent, respectively).
●Of children who are reunited with their families, 20 to 30 percent reenter the foster care system within 12 months of reunification.
●Approximately 25 percent are adopted out of foster care annually. Of those who were adopted in 2021, 55 percent were adopted by their foster parent and 34 percent by a relative [4].
●Approximately 9 percent age out of the foster care system annually. While youth can emancipate from foster care on their 18th birthday, all but one state now enable young adults to remain in foster care until their 21st birthday as long as they are in job training, employed, or in school [60].
In observational studies, emancipation from the child welfare system is associated with poor outcomes, including increased risk of pregnancy before age 21 years [61] and homelessness for at least one day during the first year [25].
●The 2010 Affordable Care Act enabled the extension of Medicaid coverage until age 26 years for youth who age out of foster care. Over 40 percent of states have exercised the Chafee Option to extend Medicaid. Coverage for those who move out of state after age 18 years varies from state to state, but federal law will enable all states to provide coverage to youth alumni who move across state lines beginning in 2023 [62,63].
●Approximately 1 percent of youth continue in state guardianship beyond foster care because they are intellectually or physically disabled and deemed unable to care for themselves [4]. At age 18 to 21 years, they are transferred from foster care to state guardianship and receive care in a group home or residential facility.
●During the course of any year, under 1 percent of youth run away from their foster care placement. These adolescents are at high risk of commercial sexual exploitation, homelessness, substance use, and criminal justice involvement [64].
Comprehensive studies of the effects of reunification with birth parents compared with placement with relatives or adoption have not been conducted. A single prospective study of 149 ethnically diverse children compared children who were not reunited with reunified children and showed significantly more self-destructive behavior (15 versus -11 percent), higher rates of substance abuse (16 versus -11 percent), and school drop-out rates (21 versus 9 percent) in the reunified group [65]; the groups did not differ, however, in the prevalence of sexual behaviors, pregnancy, or school suspension.
Other outcomes studies of foster care have focused on young adults who grew up in the foster care system and have shown high rates of chronic health problems, mental health issues, relationship problems, unemployment, and homelessness [66-71].
SUMMARY
●Reason for placement – Children and adolescents are placed in foster care because there are imminent concerns about their safety. Almost all children and adolescents in foster care are placed involuntarily by court order for reasons of abuse or neglect. Admissions to foster care have decreased since 2001 as child welfare addressed issues of disproportionality, racism, and bias. (See 'Background' above and 'Reason for placement' above.)
●Foster care system
•Each family involved with the foster care system is assigned a caseworker; in addition, the child may be appointed a law guardian or court-appointed advocate who represents the child's interests in court. (See 'Foster care personnel' above.)
•The type of placement is supposed to be determined by the child's needs and should be in the least restrictive environment, ideally a family environment, but availability of the optimal setting may be limited. Options include foster care homes, kinship care homes, specialized or therapeutic foster homes, and residential treatment facilities or group homes. Foster care and kinship care family placements are the most common for children under age 12 years. (See 'Types of placement' above.)
•Birth parents retain legal guardianship of their children during foster care unless they voluntarily surrender their rights or the court terminates them through a legal process called "termination of parental rights." (See 'Birth parents' above and 'Termination of parental rights' above.)
•Visitation is a mandatory component of foster care. It is the single best predictor of reunification. (See 'Visitation' above.)
●Outcomes – The majority of children who are placed in foster care are returned to a parent or relative. Approximately one-fifth are adopted out of foster care. (See 'Outcomes of foster care' above.)
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