Adolescents in foster care have a higher pregnancy rate than those who are not in foster care. Children of adolescent mothers are also more likely to be maltreated than children of older mothers.1,2 This is perhaps one of the clearest examples of intergenerational maltreatment. The challenge is determining how to change the trajectory of the children of adolescents in foster care to decrease the unfortunate phenomenon of these children “grandchilding” into foster care.

In this issue of Pediatrics, Wall-Wieler et al3 investigate the risk of foster care placement before the second birthday for children of adolescents placed in foster care during pregnancy. They do this through a data linkage of the Population Data Research Repository at the Manitoba Centre for Health Policy and physician claims, hospitalization data, and child protection information. Mothers who were ˂18 years of age and gave birth to their first child in Manitoba County over a 15-year period ending in 2013 were included. The data set included a total of 5946 mothers, of which 9.7% (n = 576) were in foster care at the time of the birth.

The investigators are to be commended for opening the door on this complex topic. We note several concerns with the study that should be considered in future research on this topic.

The outcome measure selected for this study (placement of the infant into foster care) is not the most important outcome for children and young mothers. Avoiding unnecessary foster care placement is a worthy goal, but placement of an infant, a young child, or an adolescent mother in foster care is not a bad outcome per se. For the young child of a 15-year old girl who is not yet ready to parent, the placement of her infant or toddler into foster care may be in the best short-term and long-term interests of both the mother and child. The authors of several longitudinal studies suggest that under certain circumstances, foster care may result in better long-term outcomes than the outcomes of remaining with biological parents.4,6 Although children of adolescents in foster care were not specifically evaluated in these studies, it is important to consider whether the outcomes might be better for both mother and infant when 1 or both are in foster care. Placement into foster care is an intermediate outcome; the most important outcomes are the long-term health and well-being of the child, the mother, and the mother-child dyad. The assumption that reducing foster care placements always improves outcomes is not necessarily true and may be used to support policies that are not in the best interests of children.

Child welfare system variability may limit the generalizability of the findings. What does it mean in Manitoba County to be in foster care? Are there group homes for teenagers, and is this considered foster care? Are infants allowed in group homes? Is there kinship care, and if so, what proportion of all placements are with relatives? The system of foster care in Canada may be different from the system in the United States or Europe. Furthermore, the system in Manitoba County may be different from the system in the rest of Canada in the same way that child protective services systems differ between states and even within states in the United States. Appropriate interpretation of the study results requires a description of the child welfare system in the region in which the research is being done.

Finally, readers of this study must ask why infants born to adolescents in foster care were placed in foster care. It is possible, for example, that the newborns were placed in care because it allowed for the mother and child to be together in the same foster home. The most likely time of placement for infants whose mothers were in care was before 7 days of age, indicating that most placements occur from the hospital or shortly after being discharged from the hospital, suggesting that many of these placements were planned in the prenatal period. In contrast, the greatest likelihood for placement into foster care for adolescents not in care was between 7 days and 1 year. The ability to know the reason for placement in foster care is critical; data linkage is only as useful as the variables that are included. Multidisciplinary collaboration with child protective services might have been used to answer this question.

The authors are to be saluted for using available data to try to better understand an important issue. Determining if what is available is a good proxy for the outcome we really want is a critical step in determining if the authors of this study can provide us with the answer to the question we are asking. We believe that in their study, Wall-Wieler et al3 raise more questions than they answer. Although the authors use the study to remind readers of the need to provide strong support to adolescent mothers in foster care, we would caution readers against concluding that placing the infants or toddlers of adolescent foster children into foster care necessarily implies failure by the adolescent mother or suggests a need for additional child protective services policies focused on improving parenting skills of adolescent mothers who are in foster care. In reality, placement of these infants and toddlers in foster care may imply the opposite (ie, that adolescent mothers and/or the child protective services system recognizes that they may not be ready to parent and/or that they need support from their own foster parent so they can learn to parent). Placing the infant of an adolescent mother in foster care into foster care may not be a negative outcome, but rather the best outcome of all: safety and support for the adolescent mother, safety of her child, and an end to the intergenerational cycle of child protective services involvement.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-3119.

1
Whitson
ML
,
Martinez
A
,
Ayala
C
,
Kaufman
JS
.
Predictors of parenting and infant outcomes for impoverished adolescent parents.
J Fam Soc Work
.
2011
;
14
(
4
):
284
297
[PubMed]
2
Stier
DM
,
Leventhal
JM
,
Berg
AT
,
Johnson
L
,
Mezger
J
.
Are children born to young mothers at increased risk of maltreatment?
Pediatrics
.
1993
;
91
(
3
):
642
648
[PubMed]
3
Wall-Wieler
E
,
Brownell
M
,
Singal
D
,
Nickel
N
,
Roos
LL
.
The cycle of child protection services involvement: a cohort study of adolescent mothers.
Pediatrics
.
2018
;
141
(
6
):
e20173119
4
Davidson-Arad
B
,
Englechin-Segal
D
,
Wozner
Y
.
Short-term follow-up of children at risk: comparison of the quality of life of children removed from home and children remaining at home.
Child Abuse Negl
.
2003
;
27
(
7
):
733
750
[PubMed]
5
Davidson-Arad
B
.
Four perspectives on the quality of life of children at risk kept at home and removed from home in Israel.
Br J Soc Work
.
2010
;
40
(
6
):
1719
1735
6
Mennen
FE
,
Brensilver
M
,
Trickett
PK
.
Do maltreated children who remain at home function better than those who are placed?
Child Youth Serv Rev
.
2010
;
32
(
12
):
1675
1682
[PubMed]

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.