US Foster Research Articles

Minimum wages and foster care placement disruption

AbstractWe examine the potential secondary impacts of raising the minimum wage in a jurisdiction on the efficiency of its foster care placement system. We employ the Adoption and Foster Care Analysis and Reporting System (AFCARS) restricted‐access dataset representing all children in the US foster care system for the years 2000–21. We calculate placement efficiency as the number of yearly moves experienced by a child in the foster care system, with a decrease in the number of placements interpreted as benefitting children both psychologically and behaviourally. This increase in stability benefits the foster parents and corresponds to a smaller financial strain on the public. After including various controls and state‐year fixed effects, our Tobit and Ordinary Least Squares (OLS) analyses find that increased minimum wages are significantly associated with lower levels of placement disruption. We take this as promising initial descriptive evidence for the secondary effects of the minimum wage on reducing the financial burden, and increasing the placement efficiency, of the foster care system.

Understanding the health and well-being of adults 10-15 years after adoption from the US foster care system

ABSTRACT Young adult adoptees surveyed 10-15 years after exiting the child welfare system to adoption reported that they were in good or excellent physical health; did not have a substance use problem; were socially connected; had strong feelings of belonging with their adoptive family; and felt very hopeful about their future. However, adult adoptees reported much higher rates of a current mental health problem than adults in the general population. Understanding the mental health and well-being of adult adoptees can help the child welfare field, social service providers, and practitioners promote early screening for mental health concerns and identify service needs.

The Regulation of Foster Care: Using Federal Rulemaking to Update Foster Care Licensing Standards

The US foster care system is stretched far beyond its capacity due to a lack of funding, limited permanent foster child placement options, and outdated foster care guidelines. To address several of these issues, the Administration for Children and Families (ACF) enacted a rule in November 2023 to change the legal definition of “foster family home” in the Social Security Act to more closely align the foster care system with best practices. This paper explores how the ACF used federal rulemaking to modify foster family licensing standards, the implications for the foster care system, and additional recommendations that the ACF may consider to maximize the rule’s impact.

Association Between Restricted Abortion Access and Child Entries Into the Foster Care System

The 2022 US Supreme Court decision Dobbs v Jackson Women's Health Organization overturned federal protections to abortion care, allowing many states to severely restrict or ban access to abortion. Given the implications of the Dobbs ruling, there is a need to understand the full consequences of restricted abortion access. Before 2022, many states restricted access to safe and legal abortions through Targeted Regulation of Abortion Providers (TRAP) laws, which provide a historical mode for estimating the consequences of abortion restrictions. To use TRAP law enactment as a natural experiment to quantify the association between restricted abortion access and foster care entries. In this cohort study, data on the enactment of TRAP laws and case-level data on foster care entries were used to estimate the association between restricted abortion access and foster care entries in each of the 50 US states and the District of Columbia. The sample included children conceived between January 1, 1990, and December 31, 2011, who were placed into foster care at any point between January 1, 2000, and December 31, 2020. Data analysis was performed from January 2023 to July 2023. Restricted abortion access due to state-level TRAP laws during pregnancy. The main outcome was the number of children entering foster care in each state, measured by year of child conception. The analysis was performed using a generalized difference-in-differences design, comparing entries into foster care in states with TRAP laws to states without TRAP laws, before and after their implementation. This study included 4 179 701 children who were placed into foster care during the study period, with 11 016 561 entries. More than half of the children were male (51.4%), and the mean (SD) age was 7.4 (5.2) years. There was an 11% increase in foster care placement after abortion access was restricted in states with TRAP laws, relative to states without TRAP laws (incidence rate ratio [IRR], 1.11 [95% CI, 1.01-1.23]). These laws had significant consequences for Black children (IRR, 1.15 [95% CI, 1.05-1.28]) and racial and ethnic minority children (IRR, 1.15 [95% CI, 1.02-1.30]). The increase in entries due to TRAP laws was particularly attributable to housing inadequacy (IRR, 1.21 [95% CI, 1.11-1.32]). Restricted abortion access can have numerous consequences, and these findings reveal a heightened strain on the US foster care system, particularly affecting marginalized racial and ethnic communities and financially vulnerable families. These placements have been shown to have lifelong consequences for children and substantial costs for both states and the federal government. To further examine the widespread implications of the overturning of Roe v Wade, future studies should forecast the expected increase in foster care entries and estimate the expenditure needed to support these children.

The eel connection: Developing urban adolescents’ sense of place through outdoor interactions with a local organism

In response to growing concern about the increased disconnect between youth and their outdoor environment, this study examines how nature-based citizen science experiences with a local animal (American eels) influence urban adolescents’ (high-school students) sense of place in a US city. The juvenile American eel is a unique animal due to its see-through body, small size, lengthy migratory pathway, high periodic population density, and conservation concern. Interview, written, and observational data were collected through a case study of ten high-school students during a citizen science project that lasted three months. Analyses of these data indicate that students developed greater ­ecological place meaning and place attachment. Students developed greater ecological place meaning by learning more about the ecology of the river and the eels, and developed greater place attachment by developing pride and empathy. Based on these findings, we argue that nature-based citizen science programs can help environmental educators in the US foster more equitable access to nature by providing urban youth with much-needed opportunities to deeply experience local places and develop a closer and more meaningful relationship with their local environment.

Sleep Quality and Problems Among Children in US Foster Care

Sleep Quality and Problems Among Children in US Foster Care

The Complexity of Psychotropic Medication Prescription and Treating Trauma Among Youth in Foster Care: Perspectives from the Lived Experience.

Youth in the US foster care system are disproportionately prescribed antipsychotic and psychotropic medication compared to youth not involved with foster care. Research on the relationship between experiences of trauma, mental health symptoms, evidence-based treatment, and safe psychotropic prescribing practices for youth in foster care is limited. We explored stakeholders' perspectives of the relationship between psychotropic medications and trauma informed care (TIC) for youth in foster care. We conducted semi-structured individual and group interviews with foster caregivers, caseworkers, prescribing clinicians, and alumni of the foster care system. Data were recorded and transcribed verbatim, and analyzed using a directed content analysis approach. Five themes emerged across and within stakeholder groups: (1) acknowledging trauma; (2) role of psychotropic medication; (3) psychosocial resources; (4) additional supports; and, (5) training and education. Stakeholders identified TIC as an important component of mental health services for youth in foster care. There was not consensus around the role of psychotropic medication in treating trauma; however, most stakeholders felt that it was overused. Respondents suggested including additional supportive team members to help guide youth through the mental health treatment system, and emphasized the importance of support from individuals with common lived experiences. Results demonstrate the need for a system that emphasizes trauma-sensitive clinical interactions and psychosocial supports. Improving training and education for stakeholders, and providing additional sources of support for youth in foster care, could help better identify and treat the effects of trauma and the safe pharmacotherapy for youth in foster care.

How Are the Sleep Problems of Children in the US Foster Care System Addressed?

Evidence of poor sleep health among children in foster care continues to mount, but information about whether and how sleep problems are addressed is unavailable. The goal of this study was to begin to fill these significant knowledge gaps. Four hundred eighty-five foster caregivers from across the United States completed a survey focused on the sleep health of one child, 4 to 11 years ( M = 6.4; SD = 2.2) currently in their care. Caregivers provided quantitative and qualitative responses to questions regarding training, information, and services received in relation to their child's sleep. Caregivers also reported on the factors and strategies they perceived as most important for helping children in their care sleep well. Only 13% of caregivers reported receiving any information/education about sleep from agencies or case workers, whereas 55% had sought help from a health provider related to their child's sleep. Nearly half of all caregivers (46%) reported giving their child melatonin. Caregivers reported that a bedtime routine/consistency, reassurance of safety/love, and a calming environment were most important for helping their child sleep well. A recurrent theme in qualitative responses was a need to mitigate child fear/anxiety at night. Children in foster care face a range of risk factors that increase the likelihood of poor/insufficient sleep, but these findings suggest this critical aspect of health requires greater clinical and research attention. As these data were collected during the initial months of the COVID-19 pandemic, replication studies are necessary.

International Adoption: A Review and Update.

1. Judith Kim Eckerle, MD*,† 2. Megan Marie Bresnahan, OTR/L† 3. Maria Kroupina, PhD, LP*,† 4. Dana Ernest Johnson, MD, PhD*,† 5. Cynthia Ruth Howard, MD, MPHTM*,† 1. *Department of Pediatrics, University of Minnesota, Minneapolis, MN 2. †MHealth Fairview University of Minnesota Masonic Children’s Hospital, Minneapolis, MN * Abbreviations: Ab : : antibody ACE : : adverse childhood experience CDC : : Centers for Disease Control and Prevention CXR : : chest radiography IA : : international adoptee TB : : tuberculosis 1. Key information for accurate assessment of the preadoption referral. 2. Determining immunization status and planning catch-up strategy. 3. Updated screening protocol for and treatment of latent tuberculosis infection. 4. Evaluation of developmental delays in the context of international adoption. 5. Screening for risk factors indicating the need for referral to child mental health and developmental specialists. After completing this article, readers should be able to: 1. Review the basic components of an adoption referral file and know when to consult an international adoption medicine expert. 2. Perform the initial medical assessment of a newly arrived international adoptee, including evaluation of the efficacy of previous immunizations and planning of catch-up immunization based on new recommendations. 3. Screen for tuberculosis and treat latent tuberculosis infection based on recent Centers for Disease Control and Prevention (CDC) guidelines. 4. Understand the multiple areas of a developmental baseline of adopted children and assess for catch-up needs. 5. Identify the child with multiple risk factors and/or parental or family stressors who needs a referral to an adoption-competent mental health specialist. 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 …

Addressing Sexual Health Among Youth in Foster Care Group Homes: A Community-Engaged Grounded Theory Study

US foster youth have elevated pregnancy and sexually transmitted infection (STI) rates, yet receive limited sexual health education and intervention. Thus, we sought to co-develop a comprehensive model of sexual health needs among youth in foster care group homes through a community-engaged research process with foster youth and foster care staff to inform such intervention. Our team conducted five in-depth focus groups with both foster youth placed in group homes and foster care staff (social workers and group home staff) in 2018–2019. We analyzed the data through iterative open, focus, axial, and selective/theoretical coding using constructivist grounded theory (GT) methods to produce a model of sexual health needs among youth in foster care group homes. GT analysis revealed the model’s core category, Addressing Sexual Health among Youth in Foster Care Group Homes, has three supporting categories: reproductive health system, relationship health, and mental health. The study model offers new pathways for comprehensively addressing sexual health and well-being in this specialized population, grounded in foster youth and staff members’ direct, lived experiences. This conceptualization expands current intervention options beyond pregnancy/STI education programs alone to a holistic, multilevel focus on the interrelated need for trauma-informed family planning and contraception care, mental health and substance use care, sexual and emotional safety, and healthy relationships.

All-Cause Mortality Among Children in the US Foster Care System, 2003-2016

All-Cause Mortality Among Children in the US Foster Care System, 2003-2016

End-of-life trends and patterns among children in the US foster care system: 2005–2015

Drawing on national, longitudinal Adoption and Foster Care Analysis, and Reporting System data (2005–2015), demographic, health, foster care, and geographic characteristics of decedents (N = 3653) aged 1–17 years were examined. On average, decedents were 6 years old, the highest proportion died as infants, and experienced significant trauma in their short lives either through maltreatment or exposure to parental substance use. A noted increase in Medicaid coverage among decedents over time suggests critical access to concurrent treatment and hospice care, but this is unavailable to children with private insurance. This study has policy implications related to the 2010 Affordable Care Act.

Serious Illness and End-of-Life Quality for US Foster Children: A National Study.

Of the nearly 500 000 children in foster care, several hundred children die each year. Their quality of life at end of life is a matter of their foster care experience. The purpose of this study was to investigate whether serious illness was associated with foster care placement outcomes. US foster care data from 2005 to 2015 were used. Children who were younger than 18 years with residence in the United States were included. Serious illness (ie, physical health, mental/behavioral health, developmental disabilities) was measured via the foster care files. Two foster care placement outcomes were created (ie, type of placement, placement instability). Using multinomial and logistic regressions, the influence of serious illness on placement outcomes was evaluated while controlling for demographic, geographic, prior trauma, and foster care support characteristics. Fifty-seven percent of the children were placed with nonrelatives, 27% in group homes/institutions, and 17% with relatives. Twenty-eight percent experienced placement instability. Serious illness was significantly associated with nonrelative (relative risk ratio [RRR] = 1.97; 95% confidence interval [CI] = 1.58-2.45) and group home/institution placement (RRR = 2.67; 95% CI = 2.09-3.40). Serious illness was not significantly related to placement instability. Children with serious illness were no more likely than their peers to experience multiple foster care placements. Foster care youth at end of life were more likely to be placed with nonrelatives or in group homes/institutions. They also did not experience the disruption and stress of being moved to multiple foster homes while seriously ill.

Health out of foster care as young adults age out of foster care: A phenomenological exploration of seeking healthcare services after aging out of the US foster care system

Some adolescents in the United States who have been abused and/or neglected by caregivers and placed in permanent custody of the state leave, or “age out” of foster care at 18 years of age. Poor health outcomes among individuals who age out are notable, yet few studies describe the phenomenon of seeking healthcare services after leaving foster care. The investigators specifically queried the phenomenon of seeking healthcare services after foster care drawing from the Phenomenology of Practice approach. We interviewed 13 young adults who aged out of care. Investigators extracted lived experience descriptions (LEDs) from interview transcripts and analyzed under phenomenological themes. Healthcare experiences were marked by avoiding self-disclosure, having no choice but to wait, missing family history, and relying on the kindness of strangers. Healthcare providers who integrate the findings into care delivery models will engage young adults with more understanding and sensitivities of ethical practice.

A Literary Perspective on Foster Care in the United States

One thing I appreciate about psychiatry is the field’s consideration of a patient as a person with a life outside of the doctor’s office. Yet, as medical school drew to an end, I knew little about one particular patient population I anticipated serving as a future child psychiatrist: children in foster care. According to the US Children’s Bureau, the number of children in foster care served nationally decreased almost 19% (from 797,000 to 646,000 children) between 2005 and 2012, but now is on the rise again with 653,000 served in 2014.1 Approximately 50% of children who enter the foster care system are returned to their parents, but 20-30% of those children will reenter the system within one year.1 In most states, children age out of the system at age 18 with no support and no one to turn to in a crisis; between 11% and 36% of those who age out become homeless, and only 40% find employment.2 A recent study in Pediatrics showed that former foster children are 2.3 times more likely to report poor general health than economically secure young adults.3 This is congruent with chronic stress research, which shows that exposure to chronic stressors can lead to adverse health outcomes. Studies show that 80% of children in foster care have significant emotional and behavioral problems.4 Tragically, behavioral health service use drops by 60% within a month of discharge from foster care, and 90% of young adults with externalizing disorders who were formerly in foster care are arrested within 1 year of aging out.2 What is the US foster care system that produces these sobering outcomes? To begin to answer this question, I started from a historical perspective to learn how the system developed and how it currently functions.

Orphans of our Reading: The Narrative Journalism of Foster Care

This essay examines two long-form journalistic accounts of the contemporary US foster care system: New York Times reporter Nina Bernstein’s The Lost Children of Wilder (2001), and Life for Me Ain’t Been No Crystal Stair (1993), by The New Yorker’s Susan Sheehan. Beginning with the divergent responses such accounts of foster care typically generate in readers and reviewers, the essay then explores the popular legacy of Victorian-era depictions of “foundlings,” “lost boys,” and orphan girls. Then, it turns to the rival narrative forms Bernstein and Sheehan use—what I term the Dickensian and modernist modes, respectively—to represent the legal, social, and emotional turmoil surrounding the foster care system. Along with examining the relationships these journalists form with their subjects, and the rival modes of governance the poor must negotiate, the essay also discusses how these writers account for, or discount, the effects of the supposed culture of poverty on foster care.

A matched case-control study comparing the health status of youth village alumni in Israel to the general population.

Recent studies have noted that disproportionately adults with histories of childhood out-of-home placements, compared to adults without, suffer adulthood psychological and physical problems; however, these findings were based mostly on research investigating adults who were in the US foster care system. Building on this foundation, this study examined adults with histories of living in another type of childhood out-of-home placement, called youth villages, a situation in Israeli society reserved for youths who come from impoverished families with the added challenge of being immigrants, from single-parent families, or having parents who struggle with mental health problems or substance abuse. This study's aim was to examine the longer term adulthood impact of having lived in youth villages on health status, by making comparisons to the general population using a sample matched by age and gender. Youth villages provided lists of alumni, ages 21-55, and telephone questionnaires were administered from November 2014 to December 2015. The adult youth village alumni (n=152) were compared to a matched sample of the general population (n=304) drawn from an existing Israeli nationwide data set. Conditional logistic regression was used to compare the health status of the two groups. Youth village alumni were found to have experienced many of the same adverse childhood events as did graduates from the US foster care system; however, after adjusting for confounders, the health status between the two groups did not differ. This dramatically different finding compared to studies on US foster care graduates suggests that the precursors of out-of-home placement and out-of-home placement itself may not always be devastating experiences with adulthood health repercussions. Future studies are needed to examine the context and process of out-of-home placement including: events preceding placement, context of assigning placement, placement itself, stability of placement, placement's fit for the youth's temperament and preparation for exit from the placement.

Adopted children's country of origin and post-adoption parent–child relationship quality: Findings from the United States National Survey of Adoptive Parents (NSAP)

In this paper, we investigated adoptive parent–child relationship quality as a function of the adopted children's country of origin, pre-adoption adversity, age at placement, age, gender, and special healthcare needs status. From the 2007 National Survey of Adoptive Parents (NSAP; N=2089), we identified 1906 families that had adopted children from the US foster care system, US private agencies, China, Guatemala, Russia and South Korea. Regression analysis showed that when country of origin was the sole predictor, adoption from the US private agencies (β=.18, p<.001), China (β=.21, p<.001), Russia (β=.06, p<.05) and South Korea (β=.07, p<.05) predicted higher parent–child relationship quality score than adoption from the US foster care system (referent) (R2=5.59%). Adoption from Guatemala was not different from adoption from the US foster care system in parent–child relationship quality (β=−.01, p>.10). In the absence of country of origin, being a boy (β=−.10, p<.05), older age at placement (β=−.20, p<.001), older age (β=−.11, p<.001), having special healthcare needs (β=−.19, p<.001), and more pre-adoption adversity (β=−.08, p<.05) all significantly predicted lower parent–child relationship quality scores (R2=17.56%). When country of origin and the above variables were entered into the regression model simultaneously, being a boy, age at placement, age, and special healthcare needs status remained significant. However, none of the countries of origin except China (β=.07, p<.05) remained significant in predicting higher parent–child relationship score. Our findings showed that the unique circumstances that fueled the availability of children from different countries to become available for adoption played some role in parent–child relationship quality. However, the adopted children's gender, age at placement, age, and special healthcare needs were more predictive of post-adoption parent–child relationship quality.

Revisiting the Adoption Assistance and Child Welfare Act of 1980: Analysis, Critique, and Recommendations

During the 1970s, record rates of families intersected with the US foster care system. An estimated 500,000 children resided in foster care and despite services provided, those children suffered longer stays in foster care, increased re-entry into foster care, and reduced family reunification. The foster care system actually promoted family instability and in response, the Adoption Assistance and Child Welfare Act [AACWA] passed. AACWA intended to promote family strength and increased service provision through the restructuring and reorganization of the child welfare system. A variety of opinions regarding the overall approach to solving this problem ultimately led to severe programmatic cuts that are still felt today, more than 30 years later. Revisiting the AACWA and providing a renewed critique yields pragmatic, feasible, and necessary policy recommendations to guide governmental bodies worldwide on behalf of the families and children they serve.

Are foster children's schools of origin always best? School quality in birth vs. foster parent neighbourhoods

AbstractResearch has documented that foster children have high rates of school mobility, and it is widely believed that this contributes to their poor educational outcomes. Recent US policies address this by attempting to minimize schools transfers for foster children; however, these policies have largely ignored the issue of school quality. The current study uses descriptive statistics and mixed factor analysis of variance to assess (i) the quality of schools attended by elementary‐aged US foster children living in a large, urban school district (n = 683); (ii) their rates of school mobility; and (iii) differences between the quality of schools located in their birth parent vs. foster placement neighbourhoods. Results indicate that these foster children were attending poor performing schools and had high rates of school transfers. For the sample as a whole and specifically for African‐Americans and Hispanics, schools located in placement neighbourhoods were higher performing than schools in birth parent neighbourhoods. For white children, however, birth parent schools outperformed placement schools. These findings highlight the importance of considering school quality, not just continuity, when making educational decisions for children in out‐of‐home care.