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Nurturing the future: children and youth in foster care

May 2, 2022

May is National Foster Care Month, a time to reflect on children, adolescents and young adults in foster care, a population with a high prevalence of trauma, loss and poor outcomes. We also honor those who provide homes for them as well as the professionals who serve them and their families.

The first foster home was founded in Massachusetts in 1892. Prior to that, children whose parents could not care for them were sent to relatives, abandoned or housed in almshouses, mental health institutions or orphanages. Some were shipped to the Midwest by train from large cities, where they found everything from families to indentured servitude. In the 1890s, the founder of the Society for the Prevention of Cruelty to Animals responded to pleas for help on behalf of a little girl who was being abused, leading to the formation of what now is the Society for the Protection and Care of Children.

It was not until 1909 that the White House Conference on Children addressed child welfare more globally, noting that children fare best in families. And it took until the mid-1930s for foster care to be codified into federal law as a government function and obtain funding through Title IV of the Social Security Act. Foster family and kinship care was conceived as a temporary respite for children whose parents could not care for them safely.

When I started doing foster care work in 1986 as a second-year pediatric resident, I discovered a group of children and teens for whom care was fragmented, health was poor, needs were seldom addressed and lives were riddled with transitions, loss and grief. I also met dedicated foster and kinship families struggling to fill the emotional void of family separation and child welfare professionals trying to obtain services for children and birth, foster and adoptive parents despite limited funding and the demands of regulations and the court system.

Numbers of children in care declined to a low of 397,091 in 2012 but have increased to nearly half a million as crises like the opiate epidemic, unaccompanied minors at the southern border and the COVID-19 pandemic stretch an overburdened system. Caseworker turnover remains high. Training and education of caregivers and child welfare workers remain inadequate. Inequities in removal, placement and outcomes persist. And the health, developmental and mental health status of children remains poor.

People often wonder how I have persisted. The children’s needs are the major driver. The dedication and passion of child welfare colleagues, the AAP and foster and adoptive parents also have inspired and sustained me.

In 1992, pediatric colleagues encouraged me to ask the AAP for help on behalf of children in foster care. Since then, we developed guidelines for health and mental health care. We advocated for shorter lengths of stay, kinship care, subsidies for adoptive parents, state-level oversight and monitoring of psychotropic medications, medical home care, supports for youths aging out of care, the first national guidelines for residential treatment facilities and more.

Though the system remains broken in many ways, I’ve witnessed improvement over the past 30-plus years. Child welfare has adjusted and adapted as our knowledge about childhood trauma and resilience, brain development and evidence-based trauma treatment has evolved.

We now stand on the threshold of transforming child welfare. Congress passed the Family First Services and Prevention Act (FFSPA) in 2018, and it fully took effect in October 2021. The legislation dramatically increased funding for family preservation. It incentivizes child welfare to implement evidence-based, in-home interventions for substance use disorder and mental health, with the goal of keeping children safely with their families. While imperfect, FFSPA responds to the science showing that removal from family is traumatic for children and parents.

I have deep gratitude for the AAP and its Washington, D.C., office. The work that began in the 1990s has grown and matured, major legislation has been enacted, and children, teens and families have benefited.

Almost every U.S. pediatrician cares for at least one child in foster or kinship care. The AAP has resources for you at https://www.aap.org/en/patient-care/foster-care/, including the 2020 clinical report Pediatrician Guidance in Supporting Families of Children Who Are Adopted, Fostered, or in Kinship Care.

There still is much left to do. Given the mental health crisis our children are enduring, it’s time to professionalize child welfare — as we did medicine a century ago — through improved education and training, and more rigorous standards. It’s time to make trauma-informed care a universal approach in child welfare and pediatrics so we identify children at risk and intervene earlier.

And it’s time for another White House Conference on Children as we recover from the pandemic and plan for the world we must create to nurture all children so they thrive.

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