Foster Care, Adoption and Kinship Care (COFCAKC) over 75 years of Pediatrics

Commentary From the Council on Foster Care, Adoption, and Kinship Care

In the 1970s and 1980s, the American Academy of Pediatrics (AAP) had a Committee on Adoption and Dependent Care, which became the Committee on Early Childhood, Adoption, and Dependent Care (COECADC). The AAP granted the Section on Adoption and Foster Care “provisional status” in 1998 and full status in 2000. Then, in 2007, a resolution to include the needs of children in foster care as a strategic priority of the AAP was voted into the top 10 at the Annual Leadership Forum. This resolution led to the creation of the Task Force on Foster Care (TFOFC), which functioned from 2007-2011. As part of sunsetting the TFOFC, a Council on Foster Care, Adoption, and Kinship Care (COFCAKC) was formed to address policy, advocacy, and education and programmatic efforts related to adoption and foster care topics. The immediate past president of the AAP, Dr. Moira Szilagyi, was named the inaugural chair of COFCAKC in 2012.

Foster Care, Adoption and Kinship Care (COFCAKC) over 75 years of Pediatrics

Rachael J. Keefe, MD, MPH, FAAP^1,2,3; Kristine Fortin MD MPH, FAAP⁴

Affiliations: ¹Department of Pediatrics, Baylor College of Medicine, Houston, TX; ²Division of Public Health Pediatrics, Texas Children’s Hospital, Houston, TX; ³American Academy of Pediatrics, Council on Foster Care, Adoption, and Kinship Care, Executive Committee Member, Itasca, IL; ⁴Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania Division of General Pediatrics, Children’s Hospital of Philadelphia

Highlighted Articles From Pediatrics

• Green M, Godfrey C. Contributions of a children’s diagnostic clinic to child welfare: services in relation to adoption. Pediatrics. 1963;32(1):131-140
• Committee on Adoption and Dependent Care. Transracial adoption. Pediatrics. 1973;51(1):145-148
• Committee on Psychosocial Aspects of Child and Family Health. Coparent or second-parent adoption by same-sex parents. Pediatrics. 2002;109(2):339-340
• Rubin D, Spring SH, Zlotnik S, Kang-Yi CD, Council on Foster Care Adoption and Kinship Care. Needs of kinship care families and pediatric practice. Pediatrics. 2017;139(4):e20170099
• Raz M, Dettlaff A, Edwards F. The perils of child “protection” for children of color: lessons from history. Pediatrics. 2021;148(1):e20210500237

Introduction

Over 75 years, publications in Pediatrics have championed the pediatrician’s role in addressing the special health care needs of children who are adopted, in foster care, and in kinship care. In celebration of the 75^th anniversary, we aim to highlight 3 important themes relating to COFCAKC: (1) the origins of racism and bias within the child welfare system that continue to this day, (2) the change in placement types and restrictions over time, and (3) the recent focus on the importance of addressing trauma that children suffer before entry into the foster care system and the continuing trauma with this system. We will also reflect on the history of COFCAKC and how societal events and changes over the past 75 years have affected the lives of the population served.

Racism and inequities

Racial inequities throughout the process of foster care placement and adoption are described from the earliest publications. COECADC publications in the 1970s document racial differences in adoption eligibility and stable placement outcomes leading to increased numbers of minoritized children in need of adoptive homes.¹ Racism is described as a cause of the disproportionality. A review of the history of adoptions from 1930-1970 noted an emphasis on “perfect” adoptive homes after World War II when more people wanted to adopt. ¹ The description of “perfect” adoptive homes starts with white parents. Children from minoritized groups were referred to as “hard to place” and “less wanted” children along with “handicapped” children.¹ In what will likely become a landmark article in our field titled “The Perils of Child “Protection” for Children of Color: Lessons From History,” Raz et al called out the historical racism within our child welfare system.⁴ Raz notes that Black children are estimated to be 50% more likely to have been the subject of a child welfare investigation.² Black children are also more likely to enter the foster care system after investigation and stay in the system longer, because they are less likely to be reunified with their families of origin or adopted into another family.² Raz notes that “the burden of the coercive aspects of the child welfare system is carried disproportionately by Black families.” Raz argues for an alternative to removal of children from homes. Raz goes on to say, “recognizing the history of our current child welfare system and the consequences of coercive family interventions is a crucial first step in envisioning alternative responses that offer services and support, including material resources, to help ensure children and families can thrive.” After three-quarters of a century, we are finally beginning to address the racist assumptions that were baked into the American child welfare system. Much of the current work of the AAP COFCAKC and the AAP Federal Child Welfare Advocacy Team acknowledges these historic racial disparities that are woven into the very fabric of the present American child welfare system and attempts to remedy their effects on children and their families.

Change in Placement Types Over Time

The 1909 White House Conference on Children declared that children fare best when raised in families. Papers published during the first quarter century of Pediatrics suggest that out-of-home placements with families are preferable to institutional care.¹ Recognizing the importance of stable and legally recognized child-parent relationships, a 2002 AAP publication supported legislative and legal efforts to make adoptions by same-sex parents possible.³ The Family First Prevention and Services Act of 2017 (P.L. 115-123) championed by the AAP promotes prevention of foster care placement through evidence-based programs that help keep birth families together safely and prioritize kinship care when that is not possible. Early Pediatrics publications do not address the advantages of kinship care versus non-relative foster care that are now known. Increasing preference for placing children in need of substitute care with kin was noted in publications in the 2000s in Pediatrics. A 2017 policy statement was the first reference to focus specifically on the needs of kinship care families, including families caring for the 8% of children who reside in kincare arrangements outside of the child welfare system.⁴ Continued advocacy by pediatricians to promote keeping families safely together is needed.

Focus on Addressing Trauma

Symptoms related to trauma experiences among children who were adopted or eligible for adoption were described as far back as 1963 in a study of the role of a hospital-based diagnostic center for adoption-related concerns.⁵ Withdrawn behavior, preferring to remain in bed, temper tantrums, and problems with toilet training were described as “symptoms suggesting affect deprivation, traumatic care, neglect.”⁵ A change in placement was recommended for more than half of patients evaluated.⁵ We now know that placement instability has a detrimental effect on behavioral health outcomes.⁶ It is astounding to see the scientific gains made in understanding the physiologic effects of trauma over the last quarter century. The 2012 toxic stress policy statement summarizes the physiology of traumatic stress.⁷ A 2021 clinical report on trauma-informed care describes how trauma impacts brain connectivity, gene expression, and immune function leading to the symptoms enumerated in the 1963 study.⁸ This knowledge can be applied to mental health care needs and treatment inadequacies identified across Pediatrics publications in the 1990s and early 2000s. Mental health and child welfare professionals were aware of and responding to the literature on childhood trauma in the early 2000s, before most pediatricians were aware of the science. A 2008 study raised concerns for overprescribing of psychotropic medication among children in foster care; 22% of children in foster care on psychotropic medication were prescribed ≥2 drugs in the same class.⁹ A recent clinical report discusses judicious psychotropic medication use through a trauma lens and calls for additional research to develop evidence-based approaches to trauma symptoms among children who have experienced maltreatment.¹. We look forward to reading such studies in the next quarter century of Pediatrics.

References

1. Committee on Adoption and Dependent Care. Transracial adoption. Pediatrics. 1973;51(1):145-148
2. Raz M, Dettlaff A, Edwards F. The perils of child “protection” for children of color: lessons from history. Pediatrics. 2021;148(1):e20210500237
3. Committee on Psychosocial Aspects of Child and Family Health. Coparent or second-parent adoption by same-sex parents. Pediatrics. 2002;109(2):339-340
4. Rubin D, Spring SH, Zlotnik S, Kang-Yi CD, Council on Foster Care Adoption and Kinship Care. Needs of kinship care families and pediatric practice. Pediatrics. 2017;139(4):e20170099
5. Green M, Godfrey C. Contributions of a children’s diagnostic clinic to child welfare: services in relation to adoption. Pediatrics. 1963;32(1):131-140
6. Rubin DM, O’Reilly ALR, Luan X, Localio AR. The impact of placement stability on behavioral well-being for children in foster care. Pediatrics. 2007;119(2):336-344
7. Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption and Dependent Care, Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012;129(1):e224-e231
8. Forkey H, Szilagyi M, Kelly ET, Duffee J, Council on Foster Care, Adoption and Kinship Care, Council on Community Pediatrics, Council on Child Abuse and Neglect, Committee on Psychosocial Aspects of Child and Family Health. Trauma-informed care. Pediatrics. 2021;148(2):e2021052850.
9. Zito JM, Safer DJ, Sai D, et al. Psychotropic medication patterns among youth in foster care. Pediatrics. 2008;121(1):e157-e163
10. Keeshin B, Forkey HC, Fouras G, MacMillan HL, Council on Child Abuse and Neglect, Council on Foster Care Adoption and Kinship Care, American Academy of Child and Adolescent Psychiatry Committee on Child Maltreatment and Violence, Committee on Adoption and Foster Care. Children exposed to maltreatment: assessment and the role of psychotropic medication. Pediatrics. 2020;145(2):e20193751