The wellbeing of foster and kin carers: A comparative study

Kinship Care

1. Sandra H. Jee, MD, MPH 1. Department of Pediatrics University of Rochester Rochester, NY 1. Mark D. Simms, MD, MPH 1. Department of Pediatrics Medical College of Wisconsin Milwaukee, Wisc Improving the Odds for the Healthy Development of Young Children in Foster Care . Dicker S, Gordon E, Knitzer J. National Center for Children in Poverty: Columbia University Mailman School of Public Health. Promoting the Emotional Well-Being of Children and Families (Policy Paper No. 2). January 2002;1–28 Children and Family Services Reviews, Part V: Most States Fail to Meet the Mental Health Needs for Foster Children . Huber J, Grimm B. Youth Law News . 2004;Oct-Dec:1–36 CWLA Standards for Health Care Services for Children in Out-of-Home Care . Washington, DC: Child Welfare League of America; 1988. Educational Experiences of Children in Out-of-Home Care . Smithgall C, Gladden RM, Howard E, Goerge R, Courtney M. Chicago, Ill: Chapin Hall Center for Children at the University of Chicago; 2004:1–77 Fostering Health: Health Care for Children and Adolescents in Foster Care . 2nd ed. Task Force on Health Care for Children in Foster Care, American Academy of Pediatrics, District II, New York State. Elk Grove Village, Ill: American Academy of Pediatrics: 2005 Healthy Foster Care America . www.aap.org/advocacy/HFCA/ On any given day, more than 500,000 children are living in state-supported foster home care. In the course of a year, more than 800,000 children experience placement in a foster home. Many of these children return home quickly, but for some, placement may extend for years and may involve care in multiple foster homes. Most of the children have experienced serious family dysfunction prior to placement, including exposure to domestic violence and to their parents’ mental health disorders, addiction, or criminal activity. Serious neglect and abuse are the most frequently stated reasons for removing children from their parents’ care. Children entering foster homes have extremely high rates of physical and mental health problems, developmental delays, and educational underachievement. As a group, children in foster care …

Assessing Quality of Care in Kinship and Foster Family Care

Internationally, there is an increasing trend toward placing children in kinship vs. foster care. Prior research suggests that children in kinship care fare better compared to children in foster care; however, the reasons for this remain unclear. We conducted a systematic review and meta-analysis to examine the hypothesis that kinship care better preserves children's connectedness to caregiver, birth family, culture, and community; which, in turn, is associated with more optimal child outcomes. Thirty-one studies were reviewed that compared children aged 0-18years in kinship care vs. foster care on levels of connectedness, three of which had outcomes that permitted meta-analysis. Findings indicated that children in kinship vs. foster care were more likely to feel connected to family in general; however, there was not a clear advantage for kinship vs. foster care for caregiver, birth parent, cultural, and community connectedness. While levels of connectedness were generally associated with more adaptive child outcomes for children in both kinship and foster care, no reviewed studies examined the hypothesis that children's connectedness may mediate the relationship between placement type and child well-being and placement outcomes. Results are discussed with respect to limitations and policy implications of the current evidence-base and the need for more rigorous research to help identify how to improve child well-being in home-based care.

To examine the influence of kinship care on behavioral problems after 18 and 36 months in out-of-home care. Growth in placement of children with kin has occurred despite conflicting evidence regarding its benefits compared with foster care. Prospective cohort study. National Survey of Child and Adolescent Well-Being, October 1999 to March 2004. One thousand three hundred nine children entering out-of-home care following a maltreatment report. Kinship vs general foster care. Predicted probabilities of behavioral problems derived from Child Behavior Checklist scores. Fifty percent of children started in kinship care and 17% of children who started in foster care later moved to kinship care. Children in kinship care were at lower risk at baseline and less likely to have unstable placements than children in foster care. Controlling for a child's baseline risk, placement stability, and attempted reunification to birth family, the estimate of behavioral problems at 36 months was 32% (95% confidence interval, 25%-38%) if children in the cohort were assigned to early kinship care and 46% (95% confidence interval, 41%-52%) if children were assigned to foster care only (P = .003). Children who moved to kinship care after a significant time in foster care were more likely to have behavioral problems than children in kinship care from the outset. Children placed into kinship care had fewer behavioral problems 3 years after placement than children who were placed into foster care. This finding supports efforts to maximize placement of children with willing and available kin when they enter out-of-home care.

How does kinship and foster care differ on caregiver-child relationship quality and child and caregiver mental health?

BACKGROUND Children may be placed in either kinship or foster care, forms of out-of-home placement (OHP), if maltreatment is suspected. The American Academy of Pediatrics has identified them as children with special health needs requiring elevated care. While North Carolina has increased support for foster care, it is unclear whether similar support exists for kinship care. Child abuse medical providers (CAMPs) were interviewed regarding their understanding and assessment of the state of the kinship care system in North Carolina, and how it can be improved.METHODS CAMPs were individually interviewed using a semi-structured, open-ended question guide to assess their perspectives on kinship versus foster care in North Carolina. Data were coded, and the analysis was conducted in an inductive manner, allowing themes and then recommendations to emerge from interviews.RESULTS The following three themes were identified: 1) providers have a foundational understanding of the kinship care system, marked by knowledge gaps; 2) children in kinship care and foster care have equivalent, elevated health needs, but children in kinship care do not receive the same level of care; 3) individual and structural changes have to be made to the interprofessional teams working within the OHP system.LIMITATIONS The study sample was small, including eight CAMPs who had relatively homogenous demographic characteristics. CAMPs typically see the worst cases of maltreatment, which may bias responses. Additionally, the majority of children in kinship care are unknown to CAMPs and may not be fully represented in responses.CONCLUSION CAMPs' responses were summarized into a set of recommendations targeting four different components of the OHP team: the general interprofessional team, policymakers and state leaders, medical providers, and social workers.

Each year more than 500 000 children enter out-of-home placement. Few outcome studies of these children specifically address high-risk sexual behavior and adolescent pregnancy. Our study investigated the relationship between living in kinship or foster care and high-risk reproductive behaviors in a nationally representative sample of women. Data from 9620 women ages 15 to 44 years in the 1995 National Survey of Family Growth were analyzed in a cross-sectional study. Three groups-foster (n = 89), kinship (n = 513), and comparison (n = 9018)-were identified on the basis of self-reported childhood living situations. Bivariate and multiple linear regression analyses were performed. The outcome variables were age at first sexual intercourse and at first conception and the number of sexual partners. After adjustment for multiple predictor variables, foster care was associated with younger age at first conception (difference: 11.3 months) and having greater than the median number of sexual partners (odds ratio: 1.7, 1.0-2.8). Kinship care was associated with younger age both at first intercourse (difference = 6 months) and at first conception (difference: 8.6 months) and having greater than the median number of sexual partners (odds ratio: 1.4, 1.1-1.8). There were no differences between the kinship and foster groups. A history of living in either foster or kinship care is a marker for high-risk sexual behaviors, and the risk is comparable in both out-of-home living arrangements. Recognition of these risks may enable health care providers to intervene with high-risk youth to prevent early initiation of sexual intercourse and early pregnancy.

After completing this article, readers should be able to:Although interest in intercountry adoption continues to be high, the numbers of international adoptions have changed dramatically since the peak in 2004 when 45,483 international adoptees (IAs) were placed in families worldwide. By 2017, the number dropped 79% to 9,387. In the United States, the receiving country for 40% to 53% of all IAs during this period, placements reflected this same trend downward from 22,989 to 4,714. The reasons behind this decline are complex and include US and international factors. (1)From 1972 through 1990, more than 50% of IAs were from South Korea. (1) These children were generally relinquished by healthy women stigmatized by single parenthood, were raised in foster families, and were provided a high level of medical care. Most Korean children adopted to the United States were infants. In contrast, adoptees from Eastern Europe, and other countries that used institutional care, arrived in large numbers in the early 1990s. Many of these children were born into low socioeconomic circumstances, were exposed to intrauterine alcohol, were cared for in orphanages, and received inadequate medical care. Considering the profound adversity experienced in institutional care settings in terms of abuse, neglect, and exposure to violence, the findings that these experiences were associated with significant medical problems as well as acute and persistent developmental, emotional, and behavioral disabilities in postinstitutionalized adoptees were not surprising. More recently, children have arrived from African countries and Haiti having lost their parents to infection, including epidemics such as Ebola; armed conflict; and natural disaster. Adopted children arriving in the United States from all over the world stimulated great interest among the membership of the American Academy of Pediatrics, catalyzing the formation of the Section on Foster Care and Adoption in 2000; the establishment of the Council on Foster Care, Adoption, and Kinship Care in 2011; and the publication of Adoption Medicine in 2014.The advent of health-care providers focused on the nuances of international adoption medicine led to research on best practice. Although international adoptions have decreased since 2004, health-care providers still care for thousands of new adoptees every year, as well as the multitude of IA children and young adults adopted in previous years. In addition, adoptions from the US foster care system have increased during the past 20 years. Except for regionally specific infectious diseases, a strong case can be made that most adoptees, whether international or domestic, share the same array of physical, developmental, and mental health challenges. Therefore, it is more important than ever that pediatricians are able to counsel all prospective adoptive families, comprehensively evaluate the physical and mental health of children in foster care and after adoption placement, and support child well-being and successful family formation. This review article summarizes the most recent recommendations for best practice in the comprehensive health-care of the internationally adopted child and his or her family.Examination of the situation in China, the principal country participating in intercountry adoption to the United States since 2004, highlights one reason why international adoptions are decreasing but also exemplifies the increase in significant medical issues. After the gradual relaxation and then termination of the 1-child policy, China has seen a dramatic increase in domestic adoptions of young, healthy children. Of those who remain institutionalized, 98% have disabilities. (2) Now, children adopted from China are older. Because these children experience longer periods of institutionalization, adoptees from China are at greater risk for secondary cognitive, emotional, and behavioral sequalae related to prolonged social deprivation. Similar changes have been observed in most countries participating in intercountry adoption during the past decade. Therefore, due to the high percentage of children in the adoption system with histories of risk factors affecting their health, it is more important than ever for parents and professionals to participate together in thorough preadoption preparation.Thirty years of international adoption medicine experience have shown us that there are no “low-risk” referrals per se given the inherent stress and loss that adoptees experience. Thus, risk to normal growth and development are never completely absent. Review of the medical and social information for a child who not only cannot be physically examined but also is from another country and health-care system is challenging. Key information to consider when doing the review is summarized in Table 1. With rare exception, the initial review of the adoption referral requires follow-up questions of the adoption agency. For example, updated anthropometric measurements, information on current developmental status, and additional laboratory screens are often indicated. Parents are asked to request these through their adoption agency.The goal of the preadoption review is to guide the adopting family in the life-changing decision being made based on expert evaluation of the available data. The review summary ideally gives the family a clear picture of resources (medical, financial, emotional, time) needed to parent a child with particular needs, what life will look like as a family, and the child’s long-term prognosis. However, without the benefits of doing a physical examination oneself and diagnostic screens in one’s own health-care setting, diagnostic and prognostic capabilities are limited. Counseling parents about the range of outcomes and the limits of prognostication is needed to ensure that they are realistic and well prepared to welcome their IA into the family. Encouraging adoptive parents to examine their long-term social, medical, and educational expectations for their adopted child in the context of the range of outcomes is important as well. The better equipped a family is from the beginning, the higher the odds for a successful placement. Because interpretation of medical information can vary greatly depending on the referring country, the age of the child, and the nuances of interpretation by region, consultation or referral to a clinician who specializes in adoption medicine can be a valuable resource for families.A comprehensive medical assessment of the newly arrived IA is recommended within 2 to 3 weeks of arrival at his or her new home. The initial visit focuses on addressing parents’ immediate concerns; establishing a baseline for growth, development, and mental health; identifying and addressing immediate and long-term medical needs; screening for infectious diseases and nutritional deficiencies; determining the immunization status; and providing support for a healthy transition and strong attachmentIdeally, at least 1 hour of face-to-face time is needed to accomplish these goals. Before the visit, obtaining and reviewing the medical records from the country of birth or from the child’s preadoption review assists the health-care provider in planning the most efficient and valuable visit for the family. A previsit questionnaire is invaluable in understanding the parents’ concerns and planning how to address each one before the clinic visit.An interpreter is recommended for children 18 months and older. An interpreter gives the pediatrician the ability to talk with the young child in his or her native language, incorporating playfulness and reassurance. For the older child, an interpreter can assist the child in telling their own story, asking questions, and understanding the numerous activities of the medical visit. Parents may ask questions of the child through the interpreter to further understand their child’s needs, likes, dislikes, and fears. The interpreter can also assist the pediatrician in understanding the medical and social history, review of systems, and special needs directly from the older child and to assess language skills. An interpreter may at times serve as a translator of the medical record, most commonly the immunization record.Depending on the country of birth, the medical and social history may be either nonexistent or extremely detailed. Accuracy is variable as well. Parents are asked to provide all documents detailing preadoption medical and social information from the country of birth, including the immunization record. Much of this information may have already been reviewed during the period from initial referral to arrival home. However, more information may be discovered by the adoptive parents during their visit to their child’s birth country, in court or other official documents. In addition, the older child typically can add to the medical history with the assistance of an interpreter. Key historical information includes country of birth; birth history, including birthweight and intrauterine drug exposure; maternal history; time with birth family; reason for loss of birth family; time in foster care and/or orphanage; number of transitions between caregivers; developmental screening; and medical history, including laboratory screens for human immunodeficiency virus, syphilis, and hepatitis B and an immunization record. In addition, the child may have received a class B waiver from US State Department physicians before leaving the country of birth, which allows the child to enter the United States but requires follow-up. For example, a child with a positive screen for TB and normal chest radiographic (CXR) findings will receive a class B waiver.For some IAs this may be their first complete physical examination. A full examination including genitalia may be traumatizing, and, if so, the better option is to complete the examination over subsequent appointments. Many IAs have had frightening experiences in medical facilities without the comfort of an adult to buffer the trauma, for example, of a painful procedure. Examining the child while he or she sits on the lap of the parent or for the older child, encouraging his or her parent to stand close by the examination table or hold the child’s hand is not only comforting but may be absolutely necessary to do the examination. Of note, the physical examination of an IA is unique in that a head circumference is measured for all children regardless of age; special attention is given to the evaluation of undernutrition, including stunting; and close attention to facial features suggesting fetal alcohol effects and heightened vigilance for previously undiagnosed medical problems are imperative. In addition, the epidemiology of diseases in the country of birth is important to consider on physical examination. For example, increased attention for splenomegaly in a child from a region endemic for malaria or lymphadenopathy on examination of a child from a region with a high prevalence of tuberculosis (TB). Pediatric audiology and ophthalmology referral is recommended for all IAs due to the high prevalence of hearing and vision problems in this population. (3)A battery of laboratory tests is recommended for the newly arrived child. These are summarized in Table 2. Baseline laboratory screens indicated for all IAs are outlined and updated periodically in the American Academy of Pediatrics Red Book and on the Centers for Disease Control and Prevention (CDC) website. Laboratory screens performed in the country of birth should be repeated in the United States. Specific tests are indicated depending on the country of birth, infectious diseases endemic in that region of the world (see the CDC Yellow Book online), and the prevalence of genetic differences there. Intentional efforts to ensure minimal trauma are important. For example, applying a topical anesthetic to minimize pain with blood draws and, if available, having a child life specialist accompany the child and parents to the laboratory alleviates anxiety and pain.TB infection and intestinal parasites are the most common infections diagnosed in IAs. All IAs who are at least 2 years old are screened for TB before traveling to the United States. Further evaluation is performed in the country of birth if the screen is positive. However, repeated screening on arrival in the United States should be performed. The prevalence of latent TB infection among IAs is as high as 27%. (4) BCG vaccine does not prevent infection, and neither is it a contradiction to doing a tuberculin skin test. The CDC recommends that children younger than 2 years should be screened for TB with a tuberculin skin test. Children 2 years and older, may be screened with an interferon-γ release assay, either T-Spot.TB® (Oxford Immunotec Ltd, Abingdon, United Kingdom) or QuantiFERON® (Qiagen Inc, Germantown, MD). (5) If either the tuberculin skin test or the interferon-g release assay is positive, a CXR must be performed. If the CXR is negative and the physical examination reveals no sign of TB disease, the diagnosis is latent TB infection. Treatment is indicated with daily isoniazid for 9 months for children younger than 2 years. Children 2 years and older may be treated with either isoniazid daily for 9 months or once-weekly, directly observed isoniazid and rifapentine for 12 weeks. (6) Monthly appointments with the primary care team are recommended to check for compliance, dosage adjustment for weight gain, and activation to disease. If CXR is positive or signs of TB on examination are found, referral to or consultation with a pediatric infectious disease specialist is indicated. If the initial screen is negative, a repeated screen is recommended 3 to 6 months after arrival home. (7)Giardia intestinalis is the most common intestinal parasite, followed by Blastocystis hominis. Infected children may have no symptoms predictive of infection. Examination of 3 stool samples for ova and parasites and 1 stool sample for Giardia antigen is recommended. Early-morning collection of stool with 24 hours between specimens is ideal for accurate assessment of the parasite load. (8) Screening serologic testing for schistosome species, Strongyloides stercolis, and filarial species are indicated for all children arriving from countries endemic for these invasive parasites. In addition, all children with eosinophilia (absolute eosinophil count, >450 cells/mm3) should be tested for invasive tissue parasites based on the epidemiology of invasive tissue parasites in their country of birth, as noted previously herein. Toxocara canis, which can cause extremely high eosinophilia, should be considered. Ascaris lumbricoides, identified on stool screen for ova and parasites, may cause eosinophilia as it travels through the body. Both T canis and A lumbricoides are widespread and invasive parasites.Children from malaria-endemic regions may be infected without symptoms. For asymptomatic children, malaria polymerase chain reaction is recommended, if available. Polymerase chain reaction can detect all 5 species of Plasmodium: Plasmodium falciparum, Plasmodium ovale, Plasmodium vivax, Plasmodium malariae, and Plasmodium knowlesi. (4) Thick and thin blood smears every 12 hours to look for malaria parasites are indicated for all febrile, newly arrived IAs from an area endemic for malaria. For severe cases of malaria, the CDC Malaria Hotline (770-488-7788) is available for consultation.Toddlers arriving from regions with a high prevalence of hepatitis A may be acutely infected, completely asymptomatic, yet shedding hepatitis A virus. The CDC recommends that all household members and other close contacts (eg, regular babysitters) of children arriving from countries highly prevalent for hepatitis A should be immunized before the child arrives home. (9)Internationally adopted children younger than 10 years are not required to receive immunizations before arrival in the United States; however, adoptive parents must sign an affidavit that their adopted child will be immunized according to requirements within 30 days of arrival in the United States. More than 90% of IAs arriving in the United States have not been immunized per Advisory Committee on Immunization Practices guidelines. Many vaccines recommended in the United States, for example, measles, mumps, and rubella, varicella, and 13-valent pneumococcal conjugate vaccine, are not available in resource-limited countries. Measles vaccine is given as a single antigen. Screening antibody levels are recommended for infants and children 6 months or older with documentation of immunizations with 2 caveats. First, repeated immunization with inactivated polio vaccine rather than testing antibodies is recommended per the CDC catch-up schedule unless there is documentation that the child received the US- or World Health Organization–approved inactivated polio vaccine series. (10) Second, screens for pertussis antibody level do not correlate with immunity to whooping cough. Seroprotective diphtheria and tetanus antibody levels may correlate with Bordetella pertussis immunity if the child received vaccinations containing the pertussis antigen.Common parental concerns at their first medical visit with their child have to do with eating, sleeping, growth, developmental milestones, medical issues identified in the country of birth, and school placement for a school-age child. Other questions can surface regarding the actual age of the child, effects of possible intrauterine exposure drugs and alcohol, known traumatic events, or a history of physical or sexual abuse. Parents are typically seeking advice to make their child’s transition to a new culture minimally traumatic and to lay a solid foundation for attachment. Primary care professionals can help by first maximizing physical health. In addition, referral to pediatric rehabilitation experts may be indicated when there are signs of developmental delays beyond those expected for orphanage care. Referral to mental health services should be considered when issues such as indiscriminate friendliness, anxiety, or distress are identified, especially when symptoms continue beyond the first few months after arrival. Close follow-up by the primary care physician is indicated to monitor the child’s transition to his or her new culture and family, attachment, and growth and development as well as to follow up on any acute or chronic medical concerns. In addition, increased vigilance for future concerns, such as precocious and/or accelerated puberty (11)(12) or academic challenges, is prudent.Numerous risk factors may impact any area of an IA’s development. For example, multiple transitions impact a child’s ability to learn routines or identify an adult caregiver as an “anchor” for developmental exploration. Acquisition of gross and fine motor skills can be delayed due to lack of opportunity and resources to address neurologic and orthopedic needs. care development, as does of such as and problems such as hearing or vision loss can other systems, as does exposure to alcohol, or infection. care, if prolonged is associated with developmental and is a common risk for a child in institutional care, in symptoms with or to such as and For example, if an is not and/or provided with the system may not learn how to or how to the first 6 months after arriving most IAs make with and a The parent may of skills by providing for developmental with and to their child’s needs and by encouraging developmental skills. and in the and daily activities can support all of development. For most initial of developmental delays in the first 3 months rather than immediate referral to physical, or is recommended. to parents is best by with another adult such as a If delays are however, may be evaluation is recommended if delays beyond 3 to 6 months after all of development is beyond the of this article, but delays in may be in that the symptoms may be more and assessment more than assessment of other of development with parent developmental experience of every to experiences is a of numerous including and The not in the and of and the American Academy of Pediatrics has recommended in this however, have it to address with given the widespread and trauma that this has With the of may be as one of the of a comprehensive The typically of daily and school and as well as regular appointments for which may be can impact sleeping, eating, to a new and and of to and/or include the may have a of signs and symptoms from multiple with significant from child to child and should be examined with a team to ensure that medical and needs are being with skills which may as or or information can be for children are not well. If a child is having a time the can be to for screening for common developmental concerns and planning a are summarized in Table In addition, in a child’s skills in the are available significant developmental differences they should be as per for children with developmental including further evaluation by a pediatric the multiple risk factors that have been mental health is a to adoptive families In addition, early and social exposure to a natural or armed and lack of educational and development. include long-term institutional care often with a high in an multiple sexual and/or physical abuse, neglect, and repeated loss of The adoption is only are each of these risk factors of a child’s in they a unique of risk for this population. of trauma mental health and at of a child’s a the of long-term mental health and issues in adopted children must a and have that the examination of an IA as a team is the most to help the IA the medical in such as or or can clear the for mental health providers to do their best with the child and family. this to that and long-term support to adoptive a comprehensive requires that the initial evaluation within 2 to 3 weeks of arrival must be performed with the that will address the full of risk factors. However, comprehensive mental health services are often not available. The pediatrician an in address this complex of issues a The first is a mental health screen during the initial medical examination to whether a referral is The of this initial screen is of how a child is and with the parent during times of distress and how the parent these for the first in screening are outlined in Table is important for parents to understand that the factors they provide in a and are to the child’s developmental These adoptive parents to an important in the high levels of stress experienced by a child before and during the of is in the negative outcomes associated with stress levels early in only is a with adoptive parents important in stress in the this of also a for the child to their own stress skills. These in are to long-term outcomes as the children of their adoptive parents and to on their this however, from a lack of early in adopted children may not have had the to learn how to their needs. a these children may have a with their parents and, lack the ability to a for comfort when they are in In a of more than adopted children to that This is the that only 1 child in the sample the full for a adoptive parents often to what may like from their child. these in early is to the of necessary to the developmental of adopted research has also to other factors that may the and of a including an adoptive such as their own history of trauma, mental health status, or current of the Thus, in to identifying the of the adopted child, any must include in initial on parental risk factors that may the to address early risk factors from either the child’s or the of the can in negative developmental Referral to a mental health specialist after the child arrives should be considered for the child with multiple risk factors affecting his or her mental health and/or a at risk for a child is to a pediatric mental health the of the a full evaluation with developmental testing cognitive, and motor parental and assessment of the of The that mental health services for adopted children must provide support that includes and for the child and for the follow-up 12 months after arrival with mental health and developmental is recommended for all IAs regardless of their initial of and research with internationally adopted children have that can to a of children. physical and mental health developmental and are indicated for every as indicated based on these ideally address immediate and long-term needs in a A diagnosis of health should be the child has had time to learn a new language, have an and school and as indicated. support for the child and family through each developmental is and as Adoption for Children and American Academy of The of The and the Council on Adoption and Kinship Care CDC Yellow Book Health for Centers for Disease Control and Adoption Medicine of Council for Health of the Adopted from the Council on Foster Care, Adoption, and Kinship that accompany this article, visit

What are the factors associated with educational achievement for children in kinship or foster care: A systematic review

In September 2010, 408,425 children and adolescents resided in foster care. Recent legislation highlights an increasing focus on involving pediatricians in supporting children in foster care and defines specific requirements relevant to the role of pediatricians.After completing this article, readers should be able to: Foster care is intended to provide a temporary haven for children during a time of family crisis when children are at imminent risk for harm. The goals of foster care are to promote child health, safety, permanency, and well-being. Foster care also has the mission of building on family strengths and providing birth parents with the services they need to reconnect (reunify) with their children. Because children fare best in stable and nurturing families, there has been an increased emphasis in the past decade on shortening the time to permanency through reunification, placement with relatives, and adoption. Foster care also has the obligation to prepare youth for independent living when none of these permanency options is possible.In some states, more than one third of children in foster care are in court-ordered (formal) kinship placements, arrangements in which the related (kin) caregiver may or may not be a certified foster parent. Even outside the child welfare system, somewhere between 4% and 8% of children reside with members of their extended family, neighbors, or friends for a variety of reasons.During the past decade, several studies were published reporting that children experience greater placement stability in kinship care than in nonrelative foster care, and that kin caregivers report fewer child behavior problems. Other data indicate that children in kinship care have as many issues as children in foster care, and that kinship caregivers are older, are less healthy, and have less access to services than nonrelative foster parents. However, recognizing that maintaining a child’s ties to his or her family of origin holds advantages for the child, relatively more children are being placed in kinship care as a result of child protective investigation.Other children are spending brief amounts of time in foster care while child welfare attempts to identify and investigate kinship resources. The definition of kin has expanded to include nonrelatives, such as family friends, acquaintances, and neighbors. There is little information about the outcomes of reunification with parents or kinship care, including child health and mental health outcomes and the percentage of kinship homes that undergo disruption. The vast majority of kinship placements are without oversight or subsidy, although recent federal legislation was intended to improve financial support for this group of caregivers.Children in foster care are classified as children who have special health-care needs by the American Academy of Pediatrics (AAP) because of their high prevalence of medical, emotional, behavioral, developmental, educational, and dental health-care problems. Most pediatric practitioners will encounter children and adolescents in foster or kinship care in their practices. It is important that pediatricians be familiar with the effects of childhood trauma and adversity, separation from family, and ongoing uncertainty on child behavior, mental health, and development.Pediatricians are in a unique position to identify problems, make appropriate referrals, and offer support and advice to caregivers. Foster care ideally should be developmentally appropriate and child-centered, and pediatricians can play a crucial role in offering developmentally sound advice and emotional support to caregivers about parenting traumatized children and children who have significant behavior problems. Pediatricians also should suggest ways to promote placement stability and successful permanency.Most maltreated children are not removed from their birth parents, but they appear to have the same health issues as children in foster and kinship care. The knowledge and skills that pediatricians bring to the care of children in foster and kinship care also apply to the larger population of children whose families are involved with child welfare agencies.Of 3.3 million child abuse and neglect reports in 2010, 436,321 (22%) were substantiated, and 254,000 children were removed to foster care. Over the past decade, the increasing trend toward keeping children with their birth parents or with kin caregivers after child protective investigation has reduced the total number of children in foster care. In the United States, on September 30, 2010, 408,425 children and adolescents resided in foster care, 26% in a relative (kinship) foster home, 48% in a nonrelative foster home, and 9% in either a group home or residential care setting. Of the remainder, 4% lived with a preadoptive family, 5% were on a trial discharge with their parents, and 2% were listed as “run-away.”Estimates suggest that more than 700,000 individual children have spent some time in foster care during the preceding 12 months. Census data indicate that approximately four to eight times as many children and teenagers live in informal, unregulated kinship care without child welfare involvement. Approximately 40% of those in foster care are teenagers, whereas 30% are children under age 5 years. Children in foster care range in age from birth to 21 years, although 47 states still emancipate adolescents at age 18 years.Minorities are represented prominently in foster care. In 2010, 29% of children were of African American heritage, 21% Hispanic, 41% white, and 5% of two or more races. Significant concern exists that the overrepresentation of minority children reflects bias in child protective referrals, investigation, and removal, as well as a lower likelihood of reunification after removal.Discrete subpopulations in foster care that present with unique health needs include children who have multiple handicaps, teenagers involved with juvenile justice, pregnant and parenting teenagers, and unaccompanied refugee minors from countries ravaged by war or severe internal strife.The average length of stay in foster care in 2010 was 25 months, with a median of 14.5 months. The lower median is attributed to more intensive permanency planning, resulting in shorter times to reunification or placement with extended family. However, the higher mean is affected by the 25% of children who remain in care for years.Length of stay is affected by several factors: the biological family’s cooperation with the individualized case plan for their family; the availability of appropriate extended family to care for the child; diligence in permanency planning by child welfare; and the challenges of finding adoptive resources for older children, minority children, large sibling groups, and children who have significant behavioral and developmental problems.Longer stays in foster care are associated with a reduced likelihood of reunification and an increased number of placements. Approximately 50% of children and teenagers will experience more than one foster care placement, with approximately 25% having three or more placements.In 2010, of the 254,114 children who exited foster care, 51% returned to their parents and 14% went to a relative or guardian, whereas 21% were adopted and 11% aged out of foster care. The vast majority of the 27,854 individuals who aged out were emancipated at age 18 years.Because the long-term benefit of foster care placement is uncertain, admission to foster care is and should be difficult.Almost all children entering foster care are placed involuntarily by court order after child protective investigation. Child neglect, including lack of supervision or neglect of basic nutritional, educational, and medical needs, is the most commonly cited reason for placement. Overall, approximately 70% of admissions are for maltreatment. Teenagers tend to be placed for disruptive behaviors through either the juvenile justice system or as persons in need of supervision. Voluntary placements constitute less than 1% of admissions and often are made by families as a means of accessing treatment services for a child or teenager who has complex mental health or medical problems.Families whose children reside in foster care come from all walks of life, but financial poverty remains a pervasive common factor underlying foster care placement (>50% of children live with impoverished families before foster care). Poverty, however, extends beyond the financial to the lack of the normal, predictable, nurturing environment that promotes good developmental and emotional health. Most children have experienced childhood adversities beyond maltreatment, including exposure to significant violence in their homes (84%) or communities (48%).At placement, investigators report that 84% of caregivers have significantly impaired parenting skills, coupled with mental health problems (46%), substance abuse (48%), criminal involvement, or cognitive impairment (12%). Parents often lack social supports, have limited education and high unemployment, and are single.Approximately one third of birth parents admit to being abused or neglected as children, and about the same percentage spent time in foster care. Children often have had multiple caregivers even before placement in foster care. Removal of a child often follows prolonged involvement with child welfare agencies, with the removal occurring after preventive strategies have been exhausted, when the child’s health and safety are at imminent risk.Mounting evidence indicates that early childhood trauma or multiple adverse childhood experiences, and chronic stress are associated with poor short- and long-term mental health, developmental, and physical health outcomes. Trauma exposure and chronic stress, especially in the absence of ameliorating protective factors, alter the neurobiology of the brain, especially in a very young child. Chronic stress predominantly alters those areas of the brain involved in cognition, rational thought, emotional regulation, activity level, and attention.Thus, children entering foster care with their cumulative early life traumas and adversities are children who have immense emotional, developmental, and physical health needs. Studies on resiliency and recovery are just now accumulating, but early data indicate that stability in a nurturing and responsive family promotes healing after childhood traumatic experiences.Entry into foster care is fraught with uncertainty, upheaval, and losses for children. Despite high levels of family dysfunction, removal from the family of origin and all that is familiar is another emotionally traumatizing experience for many children, whereas, for other children, placement in foster care may be the first time they have felt truly safe. Although stable placement in a quality foster home can promote healing, the ongoing uncertainties and losses endemic to foster care may erode a child’s sense of well-being over time.Recent legislative activity highlights an increasing focus on involving pediatricians in supporting children in foster care. The Fostering Connections to Success and Increasing Adoptions Act of 2008 (www.fosteringconnections.org) requires foster care agencies to identify kinship resources at entry to foster care, promote and support kinship care, maintain children in their schools of origin, support Native American tribes in keeping children within tribal foster care systems, and enhance resources for youth, with a goal of independent living.Most significantly for pediatric health professionals, Fostering Connections requires states to develop health systems for children in foster care, involve pediatricians in the development of such health systems, improve health-care coordination, promote the use of medical homes, monitor psychotropic medication use, and measure health outcomes.The foster care system is simple in its concept of providing needy children with nurturing families, but also complex in practice. Federal legislation determines patterns of funding and regulatory guidelines, but responsibility for the implementation of foster care programs resides with state social service agencies, which may, in turn, delegate daily management to county or private child welfare agencies. Despite Herculean efforts by dedicated professionals, the foster care system remains burdened by huge caseloads, limited funding, birth parents who have multiple intractable problems, and bureaucratic, legal, and ethical demands that sometimes appear to be in conflict with each other.Each child welfare agency is responsible for hiring and training caseworkers for what is a complex job, requiring multiple skills commensurate with masters’ level social work. Most casework positions are, however, entry-level jobs requiring no more than 2 years of college education in many agencies. As case managers for the biological family, caseworkers must engage parents around the care of their children while making diligent efforts to assist them with securing whatever educational or service resources are necessary (eg, housing, mental health, parenting education, medical care, and drug and alcohol rehabilitation) to promote reunification.Meanwhile, caseworkers also must coordinate educational, developmental, medical, and mental health services for children, and support the foster parents in their care. When birth parents are noncompliant or unable to undertake the work necessary for reunification, caseworkers have the delicate task of supporting them through the process of alternate permanency planning. Caseworkers also are expected to help children develop secure attachments and a sense of belonging to a different family than their family of origin.Caseworkers also recruit, train, monitor, and annually recertify foster parents. They must have a working familiarity with the legal system in their state, particularly family court and the juvenile justice systems. Within 72 hours of removing a child from a family, the caseworker must prepare a court petition documenting the reasons for removal. For the child or adolescent remaining in foster care, the caseworker must return to court at designated intervals to provide ongoing documentation for the continuation of placement and to detail their own efforts on behalf of parents and children toward reunification.Every child in foster care is represented in court by a law guardian (guardian ad litem), who may or may not be an attorney, depending on the state. In some states, in particularly difficult cases, the court also may designate a court-appointed special advocate on behalf of the child. As trained volunteers who are not attorneys, court-appointed special advocates devote many hours to investigating the child’s circumstances for presentation to the court.Ultimate oversight resides with the judicial system. Family court judges have the compelling task of deciding, based on information presented to them in court, whether a child remains in out-of-home placement after removal or not; ordering services for biological parents; and rehearing at set intervals the case for a child in out-of-home care to determine whether continued placement or an alternative permanency arrangement is warranted. Ultimately, the court decides the permanency outcome, with the hope that such a decision is based on the input from attorneys, all caregivers, child welfare agencies, mental health and other professionals, and the youth who is of sufficient age and developmental capacity to speak on his or her own behalf. Education for the legal profession regarding child development, parenting, and early childhood trauma remains limited.Foster parents are the heart and soul of the foster care system, and foster parenting is the major therapeutic intervention. Foster parents come from all walks of life, but, on average, tend to be married, be of lower middle income, have at least a high school education, be employed, and have children of their own. Many have strong religious affiliations, and most are driven by a desire to do something positive for children. Some people become foster parents with the hope of eventually adopting. A small percentage of foster parents are same-sex couples, and laws are evolving to ensure that same-sex couples can both foster and adopt children.Approximately 5% of foster families undergo specialized training to act as resources for severely emotionally disturbed or medically fragile children. However, most foster parents receive very little education about parenting children who have significant trauma histories and attachment issues. There are some elegant studies demonstrating that specific education and supports for foster parents and birth parents (such as Treatment Foster Care, and evidence-based parenting education for foster parents) improve outcomes for children, but these programs have not achieved widespread use.Reimbursement for foster parenting varies widely. Families are paid a daily board subsidy for each child in their care that is set by individual states. The rate is determined by the child’s age, health needs, and the complexity of the parenting tasks. The board subsidy is expected to cover food, shelter, personal needs, recreation, and most transportation and educational costs. A recent study shows that board subsidies cover only approximately two thirds of the cost of parenting a child in foster care.Recruitment, education, and retention of suitable foster families are some of the most compelling tasks facing child welfare agencies. Boundaries are blurred in the foster care system in terms of authority, responsibility, and accountability. Foster families retain the bulk of the daily responsibility for children and teenagers, but are accountable to caseworkers, the legal system, and the birth family for the child’s care. Legal custody remains with the birth parent until a child is freed for adoption, but the foster care agency is responsible for ensuring that a child’s needs are met and the child is well cared for.Approximately 20% of youth in foster care, mostly adolescents, reside in residential or group home placements, which can cost upward of $100,000 per child annually. Mental health services usually are available on-site, but staff turnover is high. The outcomes of group care have not been well studied, and there appears to be wide variability in the quality of such care.Although consistent visitation of a child with his or her biological parent is the best predictor for reunification, visits may be difficult for the parents and child. The tenor of the parent-child relationship is variable. Children who have been abused or severely neglected by their parents may not feel safe even in a supervised visitation setting. Birth parents may not understand the need to focus on the child during visitation and instead focus on their own issues or problems with child welfare. Birth parents may attempt to sabotage the relationship of the child with the current caregivers, and vice versa. Parents may visit inconsistently, which is confusing and frightening for children, and parental no-shows reinforce rejection and abandonment. When the parent does come, the visit ends with separation that may be challenging for both parent and child.Visitation usually progresses through stages, beginning with visits supervised by caseworkers in a neutral setting. Visits to a or the home, the visit is before eventually placement may for more with the birth but kin caregivers also may unique challenges they toward the birth are about or have to court-ordered to which the parent and other is for of visitation in which a mental health parents identify their child’s understand their child’s developmental parenting skills in parenting education and to their child in an appropriate such as or still are not because such are and and specialized is in which trained visitation prepare birth parents for help the parent stay on during the and with them to the challenges associated with children may encounter other adversities in foster care. in foster care placement, in school or child care placement, separation from the of other children entering or their foster home, by birth parents, a poor relationship with their foster being or and court are but some of the children may For an child, even one can be sufficient to is as the return of a child to foster care after reunification, placement with extended family or guardian, or adoption. on the 20% to 30% of children return to foster care, mostly as a result of a of reunification with their birth parents. but small percentage of undergo usually during an parents retain of their children in the care and custody of the state or county of social can be only as of a legal in which the the child’s legal guardian until the child either the age of majority or is parents sometimes to their children for but, more of parental involuntarily after diligent efforts at reunification have The process can years, during which time but efforts at reunification and alternative permanency planning by federal legislation in states to a child has been in foster care for of the past and when there is no compelling reason not to the and in the with which they this federal Although child as a result of the of studies on childhood early brain development, and placement has toward a to foster care, the is not to permanency based on the of the out of foster care several years Over of children adopted out of care are adopted by their foster parents, and 30% are adopted by kinship caregivers. to the most recent available there were children out of foster care in 2010, of were freed for and resided in preadoptive children without an adoptive tend to be older, minority children, to be of large sibling groups, or to have significant especially emotional and behavioral problems, that to be to parents most often child welfare efforts as an into their and the reason for the of their family. Although some parents with child welfare agencies, either to remain with a or engage in criminal that Some the child for the removal, whereas over the of their family and for the resources that child welfare them Many birth parents have trauma and histories into their own that have and Many lack the most basic of parenting skills, and removal of their children may reinforce their of and welfare agencies may children in a shelter, an foster home, or the home of a the of the court after child protective investigation. with kin caregivers is to be less traumatic the child has a relationship with The first in foster care may be with a of from child protective to health and members of the foster to foster care often are for the first several a by most child welfare as a time of emotional for the and child. Children who have severe trauma histories may to behaviors that were in their but in the setting. The majority of children are by they do not understand and or in in foster care often about they are in foster care, and children may even for the of their They about the well-being of their parents and and their They they will be in care, whether or when their parents will come for or when a parent will out of or Birth parents may make they do not or Other children them about being in foster care, to their poor and sense of children and attachments to foster parents and may their less birth parent as a in parenting or conflict between caregivers, for children and Children may not be for discharge from foster care or to a in foster care placement are traumatic for children, that each a that of rejection and for placements but include child behavior problems, limited foster parent skills, conflict between birth and foster parents, and agency a foster home may be or neglect a child’s needs, resulting in foster care is because the care is truly A responsive and nurturing foster parent a of and safety for the child, the child to the of family and to the The foster care placement is stable during the child’s time in care. The foster and birth parent conflict and work on behalf of the child. The birth parent appears for at and of the services by child welfare. Child welfare the birth parent identify and on the family’s and the crisis that to the family’s is Children receive appropriate mental health and their parents in those services as the foster care experience usually does not this in foster care are a Some have in foster care, whereas foster care through the juvenile justice system or are placed by a parent unable to their behaviors or to access appropriate mental health-care tend to have the placement they experience a variety of foster care over time family homes, group homes, residential or and between foster care, home, juvenile A small percentage of teenagers are and have significant behavior issues. teenagers may lack the educational to in or parenting teenagers are another small group who may be living with their children or placed from them they have significant mental health issues or constitute a risk to their Some teenagers foster care as unaccompanied refugee having to the United from a variety of countries after or the of their majority of adolescents in foster care reside in their are education is and they receive mental health services and adolescents in foster care have experienced childhood including maltreatment, as children in foster care. They have losses and but their including substance school and criminal may be challenging that the reasons underlying them remain in foster care are less to permanency, either through reunification or adoption. Some return to parents or relatives, but many age out at age 18 years, or are to another agency or placement care or group home care). to and for independent living is resources are Foster or kin families who remain in youth are their best and youth who identify and remain to foster parents, or other

Child abuse and neglect are common problems across the world that result in negative consequences for children, families and communities. Children who have been abused or neglected are often removed from the home and placed in residential care or with other families, including foster families. Foster care was traditionally provided by people that social workers recruited from the community specifically to provide care for children whose parents could not look after them. Typically they were not related to the children placed with them, and did not know them before the placement was arranged. In recent years many societies have introduced policies that favour placing children who cannot live at home with other members of their family or with friends of the family. This is known as ‘kinship care’ or ‘families and friends care’. We do not know what type of out‐of home care (placement) is best for children.This systematic review was designed to help find out if research studies could tell us which kind of placement is best. Sixty two studies met the methodological standards we considered acceptable. Wherever possible we combined the data from studies looking at the same outcome for children, in order to be more confident about what the research was telling us. Current best evidence suggests that children in kinship care may do better than children in traditional foster care in terms of their behavioral development, mental health functioning, and placement stability. Children in traditional foster care placements may do better with regard to achieving some permanency outcomes and accessing services they may need. Implications for practice and future research are discussed.Executive summary/AbstractBACKGROUNDEvery year a large number of children around the world are removed from their homes because they are maltreated. Child welfare agencies are responsible for placing these children in out‐of‐home settings that will facilitate their safety, permanency, and well‐being. However, children in out‐of‐home placements typically display more educational, behavioral, and psychological problems than do their peers, although it is unclear whether this results from the placement itself, the maltreatment that precipitated it, or inadequacies in the child welfare system.OBJECTIVESTo evaluate the effect of kinship care placement on the safety, permanency, and well‐being of children removed from the home for maltreatment.SEARCH STRATEGYThe following databases were searched to February 2007: CENTRAL, MEDLINE, C2‐Spectr, Sociological Abstracts, Social Work Abstracts, SSCI, Family and Society Studies Worldwide, ERIC, PsycINFO, ISI Proceedings, CINAHL, ASSIA, and Dissertation Abstracts International. Relevant social work journals and reference lists of published literature reviews were handsearched, and authors contacted.SELECTION CRITERIARandomized experimental and quasi‐experimental studies, in which children removed from the home for maltreatment and subsequently placed in kinship foster care, were compared with children placed in non‐kinship foster care on child welfare outcomes in the domains of well‐being, permanency, or safety.DATA COLLECTION AND ANALYSISReviewers independently read the titles and abstracts identified in the search and selected appropriate studies. Reviewers assessed the eligibility of each study for the evidence base and then evaluated the methodological quality of the included studies. Lastly, outcome data were extracted and entered into REVMAN for meta‐analysis with the results presented in written and graphical forms.RESULTSSixty two quasi‐experimental studies were included in this review. Data suggest that children in kinship foster care experience better behavioral development, mental health functioning, and placement stability than do children in non‐kinship foster care. Although there was no difference on reunification rates, children in non‐kinship foster care were more likely to be adopted while children in kinship foster care were more likely to be in guardianship. Lastly, children in non‐kinship foster care were more likely to utilize mental health services.AUTHORS’ CONCLUSIONSThis review supports the practice of treating kinship care as a viable out‐of‐home placement option for children removed from the home for maltreatment. However, this conclusion is tempered by the pronounced methodological and design weaknesses of the included studies.

Interdependence. Bonds. Kinship. These and other sentient ties shape the themes of the articles in this issue's special focus on foster care. We learn about the connections between foster parents and birth parents, kinship and foster care, and caregiving grandparents and grandchildren. Such connections are peculiar to and distinguish social work's approach to understanding and working with human problems of living. The profession's hallmark has been its traditional commitment to context and relationship and to the precept of “person-in-situation,” beginning with the friendly visitor's concern with the family as a whole. This commitment was central in the era of the settlement house movement with its interest in the culture, community, neighborhood, and heritage of its members, as well as in group work, which drew attention to the dynamic interdependence of the individual and his or her milieu. In later years, this raw, almost intuitive awareness of the essential interdependence of people was translated in...

The U.S. foster care system has undergone profound changes during the past decade. Caseload growth, increases in the number of very young children entering care, and especially problematic behaviors among some children characterize the shifting foster care population (Barth, Courtney, Berrick, & Albert, 1994; U.S. House of Representatives, 1998; Wulczyn, Harden, & Goerge, 1998). Changes among out-of-home-care clients have been accompanied by a rapid transformation in the services delivery system designed for children. Kinship care has absorbed much of the growth in foster care (General Accounting Office, 1999; Hegar & Scannapieco, 1999). Specialized or treatment foster care has found increasing favor in some states (Needell, Webster, CuccaroAlamin, & Armijo, 1998), and new paradigms of service delivery that include alterations in public finance for foster care, privatization, and managed care have been developed (Peter & Johnson, 1999, Wulczyn, Zeidman, & Svirsky, 1997). When systems of care undergo fundamental changes such as these, it is important to understand outcomes for the clients the systems are designed to serve. Although child welfare researchers are making significant contributions toward developing an understanding of foster care outcomes, the primary clients of this system--children--have been given few opportunities to contribute to the literature. Researchers now have increased opportunities to understand the case characteristics and case outcomes of children in the foster care system. Administrative data systems in several large states allow extensive analysis of factors such as caseload dynamic, s, entries and exits from care, reunification, and adoption. Each of these outcomes now can be analyzed by subgroup (for example, age and ethnicity), placement type, placement reason, placement region, and various other factors (Needell et al., 1998; Wulczyn et al., 1994). Surveys and focus groups with social workers, interviews with children's care providers, and case record extraction also have been used as methodological tools to help explain the phenomenon of foster care. Yet relatively little research has included children as research participants. In fact, some of the seminal works in child welfare research have excluded children from participating directly in the research enterprise (Fein, Maluccio, & Kluger, 1990), unless their voices were captured through interviews conducted primarily for clinical purposes (Fanshel, & Shinn, 1978). This limitation in foster care research has been widespread, despite the fact that children's perspectives on their experiences in care could inform the service delivery system. Despite the importance of including children's voices in child welfare research, their relative absence from the literature is not surprising. Administrative, political, legal, and pragmatic barriers all conspire to limit researchers' access to and contact with foster children. This article discusses some of the methodological issues raised in one study conducted in California. The study sample included 100 children ages six to 13 residing in kinship or nonkinship care for a minimum of six months. The study used face-to-face interviews with the children in the homes of their caregivers and was built on previous work by the investigator (Berrick, Needell, Shlonsky, & Simmel, 1998), also involving interviews with the children's kin and nonkin foster parents. Children's interviews lasted approximately one hour. The interviews were designed to assess children's experiences of care in four fundamental domains: their experience of safety, their understanding of and contact with family, their experience of permanency, and their experience of caregiver support for their overall well-being. On the basis of our experience, we review in this article three of the most challenging issues that may be faced in conducting research with children in foster care: (1) recruitment of the study sample, (2) development of the study instrument, and (3) selection and training of interviewers. …

This Campbell systematic review examines whether kinship care is more effective than foster care in ensuring the safety, permanency and wellbeing of children removed from their home for maltreatment. The review summarizes findings from 102 studies involving 666,615 children. 71 of these studies were included in meta‐analyses.Kinship care is a viable option for the children that need to be removed from the home for maltreatment. However, policy issues remain to balance the cost‐effectiveness of kinship care with a possible need for increased levels of caseworker involvement and service delivery. A considerable number of the included studies showed weaknesses in their methodologies and designs. There is a need to conduct more high quality quantitative studies of the effects of kinship care based on robust longitudinal designs and psychometrically sound instrumentsAbstractBACKGROUNDEvery year a large number of children around the world are removed from their homes because they are maltreated. Child welfare agencies are responsible for placing these children in out‐of‐home settings that will facilitate their safety, permanency, and well‐being. However, children in out‐of‐home placements typically display more educational, behavioural, and psychological problems than do their peers, although it is unclear whether this results from the placement itself, the maltreatment that precipitated it, or inadequacies in the child welfare system.OBJECTIVESTo evaluate the effect of kinship care placement compared to foster care placement on the safety, permanency, and well‐being of children removed from the home for maltreatment.SEARCH METHODSWe searched the following databases for this updated review on 14 March 2011: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, CINAHL, Sociological Abstracts, Social Science Citation Index, ERIC, Conference Proceedings Citation Index‐Social Science and Humanities, ASSIA, and Dissertation Express. We handsearched relevant social work journals and reference lists of published literature reviews, and contacted authors.SELECTION CRITERIAControlled experimental and quasi‐experimental studies, in which children removed from the home for maltreatment and subsequently placed in kinship foster care were compared with children placed in non‐kinship foster care for child welfare outcomes in the domains of well‐being, permanency, or safety.DATA COLLECTION AND ANALYSISTwo review authors independently read the titles and abstracts identified in the searches, and selected appropriate studies. Two review authors assessed the eligibility of each study for the evidence base and then evaluated the methodological quality of the included studies. Lastly, we extracted outcome data and entered them into Review Manager 5 software (RevMan) for meta‐analysis with the results presented in written and graphical forms.RESULTSOne‐hundred‐and‐two quasi‐experimental studies, with 666,615 children are included in this review. The 'Risk of bias' analysis indicates that the evidence base contains studies with unclear risk for selection bias, performance bias, detection bias, reporting bias, and attrition bias, with the highest risk associated with selection bias and the lowest associated with reporting bias. The outcome data suggest that children in kinship foster care experience fewer behavioural problems (standardised mean difference effect size ‐0.33, 95% confidence interval (CI) ‐0.49 to ‐0.17), fewer mental health disorders (odds ratio (OR) 0.51, 95% CI 0.42 to 0.62), better well‐being (OR 0.50, 95% CI 0.38 to 0.64), and less placement disruption (OR 0.52, 95% CI 0.40 to 0.69) than do children in non‐kinship foster care. For permanency, there was no difference on reunification rates, although children in non‐kinship foster care were more likely to be adopted (OR 2.52, 95% CI 1.42 to 4.49), while children in kinship foster care were more likely to be in guardianship (OR 0.26, 95% CI 0.17 to 0.40). Lastly, children in non‐kinship foster care were more likely to utilise mental health services (OR 1.79, 95% CI 1.35 to 2.37).AUTHORS' CONCLUSIONSThis review supports the practice of treating kinship care as a viable out‐of‐home placement option for children removed from the home for maltreatment. However, this conclusion is tempered by the pronounced methodological and design weaknesses of the included studies.