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

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 …

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.

Children in foster care are at high risk of future mental health and developmental difficulties. A number of interventions may be helpful; however, the effectiveness of interventions specifically for pre-school children in foster care is not well established. This is an important omission, since infancy and early childhood may be the optimal period for interventions to prevent future problems. The current systematic review set out to establish the existing evidence base for interventions to improve social-emotional, developmental and relational outcomes for pre-school children in foster and kinship care. Searches of online databases were undertaken in June 2023 with keyword search terms related to the study population and design. Studies utilising a randomised control design to measure the effectiveness of interventions for foster children aged 0-7years were included. The methodological quality of included studies was assessed using the Cochrane Risk of Bias (ROB-2) tool and effects evaluated using narrative synthesis and GRADE assessments of included interventions and outcomes. Searches identified 6815 results. Twenty studies, describing seven interventions, met inclusion criteria. Fifteen studies reported intervention benefits comparative to control in at least one outcome domain, with particularly good evidence for Attachment and Behaviour Catch-Up (ABC) in improving developmental outcomes. There was also evidence for Multi-Treatment Foster Care for Pre-Schoolers (MTFC-P), Kids In Transition To School (KITS), Parent-Child Interaction Therapy (PCIT) and HeadStart in improving behavioural outcomes. The findings for relational outcomes, including attachment, were mixed; however, there was some evidence for MTFC-P and ABC in reducing avoidant attachment. This systematic review contributes to our current understanding of how we might best support pre-school children in foster care. It remains unclear whether the effectiveness of particular interventions may be moderated by participant or intervention characteristics. Further research is needed to understand which interventions work best for whom in this group. Despite some variability in methodological quality and heterogeneity across studies, our findings suggest that certain interventions are likely to be helpful for young children in foster care. Dissemination and ongoing evaluation of the evidence-based interventions highlighted within this review should be implemented in clinical practice.

To report baseline mental health measures from the Children in Care study, a prospective epidemiological study of children in court-ordered foster and kinship care in New South Wales, Australia. Mental health, socialization and self-esteem were assessed in 347 children in a statewide mail survey, using two carer-report checklists, the Child Behavior Checklist (CBCL) and the Assessment Checklist for Children (ACC). Children in the study had exceptionally poor mental health and socialization, both in absolute terms, and relative to normative and in-care samples. Levels and rates of disturbance for children in foster care exceeded all prior estimates. Rates of disturbance for children in kinship care were high, but within the range of prior estimates. Boys presented with higher scope and severity of mental health problems than girls on the CBCL, while gender-specific patterns of disturbance were shown on the ACC. A moderate age effect was accounted for by children's age at entry into care. Children in care are at high risk of mental health problems. Psychological support for the children and their carers is an essential secondary prevention strategy. Implications for service delivery are discussed.

Psychosocial factors and behavioral health outcomes among children in Foster and Kinship 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

Assessing Quality of Care in Kinship and Foster Family Care

<h3>Background</h3> Children in care are at increased risk for mental health problems, related to their adverse experiences often involving maltreatment, separation from and frequent changes in caregivers. These mental health problems include reactive attachment disorder (RAD), characterised by a failure in seeking or responding to comfort from carers when hurt or distressed, and social and emotional unresponsiveness. This talk presents data from a trial with foster children presenting RAD symptoms. <h3>Objectives</h3> This talk aims to describe the ‘Nurturing Change’ trial and to present children’s baseline levels of attachment difficulties, emotional and behavioural problems. Associations between children’s attachment difficulties and several psychopathology syndromes will also be explored. <h3>Methods</h3> The ‘Nurturing Change’ study is a feasibility and pilot randomised controlled trial (RCT) of a video-feedback parenting intervention for foster and kinship carers looking after children under 7 years old, presenting attachment difficulties in the realm of RAD. RAD symptoms were assessed via caregiver questionnaires as well as the semi-structured Disturbances of Attachment Interview. Several measures of children’s emotional-behavioural functioning were also collected, including the Child Behaviour Check List (CBCL), the Strengths and Difficulties Questionnaire, and the Development and Well-Being Assessment. <h3>Results</h3> Out of more than 300 children invited to the study, the carers of nearly 100 children were initially screened for attachment difficulties using questionnaires, with 67 completing the Disturbances of Attachment Interview. Of these, 30 families proceeded to be recruited into the RCT, from which baseline data was collected (including the measures of children’s emotional-behavioural functioning). Approximately one third of children met criteria for RAD, according to the interview data. However, it is unclear if the prevalence in this sample is representative of the population of children in foster and kinship care in the UK due to low response rate and potential non-randomness of non-responses. Analyses of the remaining findings are still ongoing, but the CBCL results, for example, reveal high levels of emotional-behavioural problems, with many subscales in the clinical range, such as Externalising and Total problems. <h3>Conclusions</h3> The study brings to light the challenges of completing research in the foster care context in the UK. However, stakeholders were unanimous that research of this kind is urgently needed. The high levels of social, emotional and behavioural difficulties found highlight the vulnerability of children in care and the need for evidence-based interventions to address them. Feasibility insights for a future trial of the current intervention will be discussed. Regarding children’s psychopathology results, first, the significance of the prevalence of RAD symptoms that we found will be discussed in relation to existing data from children in foster and institutional care worldwide, as well as the limitations of a RAD ‘research diagnosis’ and the difficulties around the RAD clinical diagnosis more broadly. Second, the significance of children’s level of difficulties in the other scales and association between their psychopathology symptoms and attachment problems will be discussed.

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. …

Contact between children in foster and residential care and their birth families have an impact on children’s development and on placement stability. Contact is also important for their social relationships and sense of belonging and well-being. The aim of this study was, from children’s point of view, to describe, analyse and compare contact in residential care and foster care in terms of its frequency, visit location, feelings during and after the visits, visit difficulties, happiness with their placement, their self-confidence, future perception about their lives, and perception of their subjective well-being. We used a sample of 145 children in residential care and all the children in foster care (39), aged between 11 and 15, from the same four Portuguese districts. Results indicated that children in residential care had more contact and visits with their parents than children in foster care, being phone calls the most used way to contact the children. The majority of the children presented joy or satisfaction during parents’ visits and more diffuse feelings after the visit. Also, most of children would like to have more visits and just a minority present some difficulties in their fulfilment. Nevertheless, children in foster care had more self-confidence, optimism in relation to their future, happiness in relation to their placement and higher subjective well-being than children in residential care. In summary, it seemed that the type of placement for children at risk is more important to their future than the existence of contact with their parents.

The present article describes a pattern of abnormal responses to pain (APR) among children in care, suggestive of pain insensitivity or failure to communicate felt pain. Exploratory analyses of caregiver-reported APR were conducted within a larger epidemiological study of 347 preadolescent children in foster and kinship care. APR items were generated from clinical assessment reports and a clinician survey, during development of a psychiatric rating scale for children in care. An APR construct was identified in factor analysis. Nine per cent of the sample had scores suggesting clinically meaningful APR, with a high level of corresponding psychological disturbance. Various analyses suggest the phenomenon may be a discrete, but integral component of complex, multifaceted psychopathology. Concurrent and retrospective measures of a large number of potential risk variables did not discriminate between APR scores and other estimates of psychopathology. However, moderate correlations between APR and ad hoc measures of impulsivity, dissociative behaviours, and inhibited-avoidant attachment difficulties suggest a number of hypothesized developmental mechanisms that might be explored in further studies.

P01-336-Social and emotional loneliness in children in foster and institutional care

P-320 - Trauma and sings of psychopathology in children in foster and institutional care

EPA-0844 - Emotional and cognitive development in children in foster and institutional care - longitudinal study