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PEDIATRICS Vol. 106 No. 5 November 2000, pp. 1145-1150
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ABSTRACT |
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Abstract
Recommendation
References
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Greater numbers of young children with complicated, serious physical health, mental health, or developmental problems are entering foster care during the early years when brain growth is most active. Every effort should be made to make foster care a positive experience and a healing process for the child. Threats to a child's development from abuse and neglect should be understood by all participants in the child welfare system. Pediatricians have an important role in assessing the child's needs, providing comprehensive services, and advocating on the child's behalf.
The developmental issues important for young children in foster care are reviewed, including: 1) the implications and consequences of abuse, neglect, and placement in foster care on early brain development; 2) the importance and challenges of establishing a child's attachment to caregivers; 3) the importance of considering a child's changing sense of time in all aspects of the foster care experience; and 4) the child's response to stress. Additional topics addressed relate to parental roles and kinship care, parent-child contact, permanency decision-making, and the components of comprehensive assessment and treatment of a child's development and mental health needs.
More than 500 000 children are in foster care in the
United States.1,2 Most of these children have been the
victims of repeated abuse and prolonged neglect and have not
experienced a nurturing, stable environment during the early years of
life. Such experiences are critical in the short- and long-term
development of a child's brain and the ability to subsequently
participate fully in society.3-8 Children in foster care
have disproportionately high rates of physical, developmental, and
mental health problems1,9 and often have many unmet
medical and mental health care needs.10 Pediatricians, as
advocates for children and their families, have a special
responsibility to evaluate and help address these needs.
Legal responsibility for establishing where foster children live and
which adults have custody rests jointly with the child welfare and
judiciary systems. Decisions about assessment, care, and planning
should be made with sufficient information about the particular
strengths and challenges of each child. Pediatricians have an important
role in helping to develop an accurate, comprehensive profile of the
child. To create a useful assessment, it is imperative that complete
health and developmental histories are available to the pediatrician at
the time of these evaluations. Pediatricians and other professionals
with expertise in child development should be proactive advisors to
child protection workers and judges regarding the child's needs and
best interests, particularly regarding issues of placement, permanency
planning, and medical, developmental, and mental health treatment
plans. For example, maintaining contact between children and their
birth families is generally in the best interest of the child, and such
efforts require adequate support services to improve the integrity of
distressed families. However, when keeping a family together may not be
in the best interest of the child, alternative placement should be
based on social, medical, psychological, and developmental assessments of each child and the capabilities of the caregivers to meet those needs.
Health care systems, social services systems, and judicial systems are
frequently overwhelmed by their responsibilities and caseloads.
Pediatricians can serve as advocates to ensure each child's conditions
and needs are evaluated and treated properly and to improve the overall
operation of these systems. Availability and full utilization of
resources ensure comprehensive assessment, planning, and provision of
health care. Adequate knowledge about each child's development
supports better placement, custody, and treatment decisions. Improved
programs for all children enhance the therapeutic effects of
government-sponsored protective services (eg, foster care, family
maintenance).
The following issues should be considered when social agencies
intervene and when physicians participate in caring for children in
protective services.
More children are entering foster care in the early years of life
when brain growth and development are most active.11-14
During the first 3 to 4 years of life, the anatomic brain structures that govern personality traits, learning processes, and coping with
stress and emotions are established, strengthened, and made permanent.15,16 If unused, these structures
atrophy.17 The nerve connections and neurotransmitter
networks that are forming during these critical years are influenced by
negative environmental conditions, including lack of stimulation, child abuse, or violence within the family.18 It is known that
emotional and cognitive disruptions in the early lives of children have
the potential to impair brain development.18
Paramount in the lives of these children is their need for continuity
with their primary attachment figures and a sense of permanence that is
enhanced when placement is stable.10 There are critical
periods of interaction among physical, psychological, social, and
environmental factors. Basic stimulation techniques and stable,
predictable nurturance are necessary during these periods to enable
optimal cognitive, language, and personal socialization skills. Because
these children have suffered significant emotional stress during
critical periods of early brain development and personality formation,
the support they require is reparative as well as preventive. The
pediatrician, with knowledge of the child's medical and family
history, may assist the social service and judicial systems in
determining the best setting to help the child feel safe and heal.
To develop into a psychologically healthy human being, a child
must have a relationship with an adult who is nurturing, protective, and fosters trust and security.19 Attachment refers to
this relationship between 2 people and forms the basis for long-term
relationships or bonds with other persons. Attachment is an active
process Optimal child development occurs when a spectrum of needs are
consistently met over an extended period. Successful parenting is based
on a healthy, respectful, and long-lasting relationship with the child.
This process of parenting, especially in the psychological rather than
the biologic sense, leads a child to perceive a given adult as his or
her "parent." That perception is essential for the child's
development of self-esteem and self-worth.21 A child
develops attachments and recognizes as parents adults who provide
"... day-to-day attention to his needs for physical care,
nourishment, comfort, affection, and stimulation."21
Abused and neglected children (in or out of foster care) are at great
risk for not forming healthy attachments to anyone.9,10
Having at least 1 adult who is devoted to and loves a child
unconditionally, who is prepared to accept and value that child for a
long time, is key to helping a child overcome the stress and trauma of
abuse and neglect.
The psychosocial context and the quality of the relationship from which
a child is removed, as well as the quality of alternative care that is
being offered during the separation, must be carefully evaluated. This
information should be used to decide which placement is in the child's
best interest. The longer a child and parent have had to form a strong
attachment with each other (ie, the older the child) the less crucial
the physical proximity will be to maintain that relationship.
Separation during the first year of life The emotional consequences of multiple placements or disruptions are
likely to be harmful at any age, and the premature return of a child to
the biologic parents often results in return to foster care or ongoing
emotional trauma to the child.22 Children with attachment
disorders and an inability to trust and love often grow up to vent
their rage and pain on society.19
Children are placed in foster care because of society's concern
for their well-being. Any time spent by a child in temporary care
should be therapeutic but may be harmful to the child's growth, development, and well-being. Interruptions in the continuity of a
child's caregiver are often detrimental. Repeated moves from home to
home compound the adverse consequences that stress and inadequate
parenting have on the child's development and ability to cope. Adults
cope with impermanence by building on an accrued sense of self-reliance
and by anticipating and planning for a time of greater constancy.
Children, however, especially when young, have limited life experience
on which to establish their sense of self. In addition, their sense of
time focuses exclusively on the present and precludes meaningful
understanding of "temporary" versus "permanent" or anticipation
of the future. For young children, periods of weeks or months are not
comprehensible. Disruption in either place or with a caregiver for even
1 day may be stressful. The younger the child and the more extended the
period of uncertainty or separation, the more detrimental it will be to
the child's well-being.21
Any intervention that separates a child from the primary caregiver who
provides psychological support should be cautiously considered and
treated as a matter of urgency and profound importance. Pediatricians
should advocate that evaluation, planning, placement, and treatment
decisions be made as quickly as possible, especially for very young
children.
The body's physiologic responses to stress are based on
involuntary actions of the brain. Physical and mental abuse during the
first few years of life tends to fix the brain in an acute stress
response mode that makes the child respond in a hypervigilant, fearful
manner.18,22 Research demonstrates chemical and electrical
evidence for this type of brain response pattern.18,23 The
age of the child dictates the developmental response and manifestations
to stress. When an infant is under chronic stress, the response may be
apathy, poor feeding, withdrawal, and failure to thrive. When the
infant is under acute threat, the typical "fight" response to
stress may change from crying (because crying did not elicit a
response) to temper tantrums, aggressive behaviors, or inattention and
withdrawal.24 The child, rather than running away (the
"flight" response), may learn to become psychologically disengaged,
leading to detachment, apathy, and excessive daydreaming. Some abused
and neglected children learn to react to alarm or stresses in their
environment reflexively with immediate cessation of motor activity
(freeze response). Older children who have been repeatedly traumatized
often suffer from posttraumatic stress disorder and automatically
freeze when they feel anxious, and therefore are considered
oppositional or defiant by those who interact with them.
The same areas of the brain that are involved in the acute stress
response also mediate motor behavior and such functions as state
regulation and anxiety control.23 Repeated experiencing of
traumatic events can lead to dysregulation in these various functions
resulting in behaviors such as motor hyperactivity, anxiety, mood
swings, impulsiveness, and sleep problems.18
An increasing number of young children are being placed in foster
care because of parental neglect.1 Neglect has very
profound and long-lasting consequences on all aspects of child
development Knowledge of normal child development and family functioning helps
identify children receiving insufficient and inappropriate care as well
as children who are victims of, or at risk for, abuse or neglect.
Comprehensive pediatric assessments can complement programs that
prevent abuse and neglect, decrease the likelihood of placement in
foster care, identify whether a child's current needs are being met,
and allow placements to be customized to meet each child's needs.
A pediatric assessment should be done within 30 days of
placement.30 This evaluation must be:
EARLY BRAIN AND CHILD DEVELOPMENT
ATTACHMENT
it can be secure or insecure, maladapative or productive.
Attachment to a primary caregiver is essential to the development of
emotional security and social conscience.20
especially during the first 6 monthsif followed by good quality of care thereafter, may not have a
deleterious effect on social or emotional functioning. Separations
occurring between 6 months and about 3 years of age, especially if
prompted by family discord and disruption, are more likely to result in subsequent emotional disturbances. This partly results from the typical
anxiety a child this age has around strangers and the normal
limitations of language abilities at this age. Children older than 3 or
4 years placed for the first time with a new family are more likely to
be able to use language to help them cope with loss and adjust to
change. These preschool-aged children are able to develop strong
attachments and, depending on the circumstances from which they are
removed, may benefit psychologically from the new setting.
CHILDREN'S SENSE OF TIME
RESPONSE TO PSYCHOLOGICAL STRESS
EFFECTS OF NEGLECT
poor attachment formation, understimulation, development
delay, poor physical development, and antisocial
behavior.8,17,25-27 Being in an environment in which
child-directed support and communication is limited makes it more
difficult for a child to develop the brain connections that facilitate
language and vocabulary development, and therefore may impair
communication skills.28 Recent findings in infant mental
health show how development can be facilitated, how treatment can
enhance brain development and psychological health, and how prevention
strategies can lessen the ill effects of neglect.29
COMPREHENSIVE ASSESSMENT OF THE AT-RISK CHILD
BEFORE PLACEMENT
COMPREHENSIVE ASSESSMENT OF CHILDREN IN FOSTER CARE
AFTER
PLACEMENT
At a minimum, the following areas should be assessed:
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TREATMENT |
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The comprehensive assessment should lead to an individualized court-approved treatment plan and ongoing monitoring by a multidisciplinary team skilled in working with this population in the context of a medical home.31 In-home monitoring, placement with a relative ("kinship care"), or out-of-home placement should support each child's psychological and developmental needs. Parents and foster parents must be well-informed about the importance of the environment in the development of normal brain function and the specifics needed for the child under care. Children can often be helped by providing predictability, nurturance, support, and cognitive or insight-oriented interventions to make them feel safe, comfortable, and loved. Specific mental health plans must be developed to meet the functional needs of each child.
Early interventions are key to minimizing the long-term and permanent effects of traumatic events on the child's brain.14,17,32-36 After the first several years of a child's life, patterns of interaction with the world are formed, both psychologically and in the brain structure, making it more difficult, though still possible, to improve a child's physical, cognitive, and emotional abilities.17 Several studies have shown how favorable and stimulating environments for infants and young children can lessen the adverse effects of prior negative environments.27 Pediatricians have an important role in recognizing problem situations in the home and for children already in foster care. Prompt referrals should be made for early intervention services to secure full developmental assessments and treatments under the Individuals With Disabilities Act.
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PLACEMENT ISSUES |
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Courts with jurisdiction over families and children have been charged by Congress and the states to ensure that "reasonable efforts" are made to preserve and repair families or to place children in foster care when necessary. The courts also have the responsibility to make foster care a healing process. Given limited social, economical, educational, and health care resources, the judiciary has a responsibility to try to make needed resources available in the community and to decide whether application of available resources has been reasonable and appropriate. An array of supportive services should be available to assist families in child rearing and to offer alternative and therapeutic parenting (ie, foster care) when temporary removal of the child from the home is required.
The measure of reasonable and appropriate should always be what is in the best interests of the child. Lack of agreement exists about what constitutes such reasonable efforts. Principles of child development and expert consultation can provide guidance to assist in determining what is in the best interest of the child and whether these interests can be best met within the biologic family or another family. The lack of available resources to ensure a reasonable effort should not be used by the protective services agencies as an excuse to delay a permanent placement plan for a child.
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PARENTAL ROLES AND KINSHIP CARE |
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The increasing number of children entering foster care, the insufficient number of suitable foster homes, and the increased interest by extended families to care for their kin have led social service agencies to place children with their extended families. Placement with a relative has psychological advantages for a child in terms of knowing his or her biologic roots and family identity. It may offer a better chance for stability and continuity of caregiving. However, little is known about the outcomes of kinship placement, and it should not be assumed to offer a superior home environment.37 Supervision by social workers of relatives providing foster care is often less intense and family support services are less available than when a child is placed in nonkinship foster care. Placement with a relative may lead to a circuitous and unintended return of the child to his or her parents.
The report by the National Commission on Family Foster Care states: "The use of kinship care has expanded so rapidly that child welfare agencies are making policy, program, and practice decisions that lack uniformity and/or a substantive knowledge base. Kinship care provides an opportunity to affirm the value of families. But the assessment process and support should include unique family strengths and needs, cultural and ethnic identification, necessary financial and service supports, continuity of care, and permanency goals."38 Studies suggest that a range of parenting arrangements can provide the feelings of permanency, security, and emotional constancy necessary for normal development.39
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VISITING (PARENT-CHILD CONTACT) |
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Children in out-of-home dependent care are usually accorded a schedule of visits with their parents. The intent is to maintain or improve the child-parent relationship, to give the social service agency an opportunity to observe and improve the parent-child interaction, and to monitor the parents' progress. The visits are frequently brief encounters occurring on a weekly basis, in a neutral setting if possible, often under the supervision of a caseworker. For younger children, this type of visit is not conducive to optimal parent-child interaction and may minimally serve the parents' needs for ongoing contact with the child or may even be harmful for the child. A young child's trust, love, and identification are based on uninterrupted, day-to-day relationships. Weekly or other sporadic "visits" stretch the bounds of a young child's sense of time and do not allow for a psychologically meaningful relationship with estranged biologic parents. For older children, such sporadic and brief visits may be sufficient to maintain a meaningful parent-child relationship.
For parent-child visits to be beneficial, they should be frequent and long enough to enhance the parent-child relationship and to effectively document the parent's ongoing interest and involvement with the child. Sporadic visits are appropriate if an older child has established a strong attachment to the parent before entering foster care or if the visits are sufficient in frequency, length, and content to contribute to the child's continuing normal development and enhanced parent-child relationship.
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STABLE PLACEMENT VERSUS LEGAL CUSTODY VERSUS PERMANENCE |
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Children who have experienced abuse or neglect have a heightened need for permanency, security, and emotional constancy and are, therefore, at great risk because of the inconsistencies in their lives and the foster care system. Every effort should be made to rapidly establish a permanent placement for the child. Tangible continuity in relationships with family and friends is essential for a child's healthy development. Stability in child care and the school environment is important. Multiple moves while in foster care (with the attendant disruption and uncertainty) can be deleterious to the young child's brain growth, mental development, and psychological adjustment.
All children, regardless of their type of placement, must receive individual attention from their caregivers. Foster parents and extended family members can play a significant role when the child's mother or father cannot. Impersonal placement settings do not effectively support young children who have been abused and neglected. Bureaucratic proceedings, including conferring legal status, are usually of little or no consequence to children, whose needs are much more fundamental. Generally, assignment of custody should reinforce a child's perception of belonging and should not disrupt established psychological ties except when safety or emotional well-being are in jeopardy.
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RECOMMENDATIONS |
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Top
Abstract
Recommendation
References
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All placement, custody, and long-term planning decisions should be individualized for the child's best interest and should maximize the healing aspects of government-sponsored protective services. These decisions should be based in part on a comprehensive assessment and periodic reassessment of the child and family by professionals who are experts in pediatrics and child development (eg, pediatrician, psychiatrist, or psychologist).22 An ongoing relationship between the pediatrician and the child and family can provide valuable insights about a child's needs and the ability of a family to meet them. Pediatricians should actively participate in prevention services for at-risk families and placement, custody, and long-term planning decisions for children for whom they provide care, taking into account the following considerations.40
The following important concepts should guide pediatricians' activities as they advocate for the child:
7. Parents should be given reasonable assistance and opportunity to maintain their family, while the present and future best interests of the child should determine what is appropriate.
8. A child's attachment history and sense of time should guide the pace of decision-making.
9. Foster care placements should always maximize the healing aspects of foster care and be based on the needs of the child.
10. Foster care placement with relatives should be based on a careful assessment of the needs of the child and of the ability of the kinship care to meet those needs. As with all foster care placements, kinship care must be supported and supervised adequately.
Committee on Early Childhood, Adoption, and Dependent Care, 1999-2000
Peter M. Miller, MD, MPH, Chairperson
Peter A. Gorski, MD, MPA
Deborah Ann Borchers, MD
Jerri Ann Jenista, MD
Chet D. Johnson, MD
Neal D. Kaufman, MD, MPH
Susan E. Levitzky, MD
S. Donald Palmer, MD
James M. Poole, MD
Liaisons
Joyce Rezin, RN, MS, CPNP
National Association of Pediatric Nurse Associates and Practitioners
Nancy Hablutzel, PhD, JD
National Council of Juvenile and Family Court Judges
Moniquin Huggins
Child Care Bureau
Mireille B. Kanda, MD, MPH
Head Start Bureau
Pat Spahr
National Association for the Education of Young Children
Phyllis Stubbs-Wynn, MD, MPH
Maternal and Child Health Bureau
Consultant
Jody R. Murph, MD, MS
Staff
Eileen Casey, MS
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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REFERENCES |
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Abstract
Recommendation
References
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This article has been cited by other articles:
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  American Academy of Pediatrics, J. Stirling Jr, and the Committee on Child Abuse and Neglect and S, American Academy of Child and Adolescent Psychiatr, L. Amaya-Jackson, National Center for Child Traumatic Stress, and L. Amaya-Jackson Understanding the Behavioral and Emotional Consequences of Child Abuse Pediatrics, September 1, 2008; 122(3): 667 - 673. [Abstract] [Full Text] [PDF]
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 A. C. Stahmer, D. Thorp Sutton, L. Fox, and L. K. Leslie State Part C Agency Practices and the Child Abuse Prevention and Treatment Act (CAPTA) Topics in Early Childhood Special Education, August 1, 2008; 28(2): 99 - 108. [Abstract] [PDF]
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 R. C. Tervo Identifying Patterns of Developmental Delays Can Help Diagnose Neurodevelopmental Disorders Clinical Pediatrics, July 1, 2006; 45(6): 509 - 517. [PDF]
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A. C. Stahmer, L. K. Leslie, M. Hurlburt, R. P. Barth, M. B. Webb, J. Landsverk, and J. Zhang Developmental and Behavioral Needs and Service Use for Young Children in Child Welfare Pediatrics, October 1, 2005; 116(4): 891 - 900. [Abstract] [Full Text] [PDF]
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C. P. Johnson, T. A. Kastner, and and the Committee/Section on Children With Disabil Helping Families Raise Children With Special Health Care Needs at Home Pediatrics, February 1, 2005; 115(2): 507 - 511. [Abstract] [Full Text] [PDF]
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D. M. Rubin, E. A. Alessandrini, C. Feudtner, D. S. Mandell, A. R. Localio, and T. Hadley Placement Stability and Mental Health Costs for Children in Foster Care Pediatrics, May 1, 2004; 113(5): 1336 - 1341. [Abstract] [Full Text] [PDF]
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L. K. Leslie, M. S. Hurlburt, J. Landsverk, J. A. Rolls, P. A. Wood, and K. J. Kelleher Comprehensive Assessments for Children Entering Foster Care: A National Perspective Pediatrics, July 1, 2003; 112(1): 134 - 142. [Abstract] [Full Text] [PDF]
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 M. B. Webb and B. J. Harden Beyond Child Protection: Promoting Mental Health for Children and Families in the Child Welfare System Journal of Emotional and Behavioral Disorders, January 1, 2003; 11(1): 49 - 58. [Abstract] [PDF]
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 R. A. Conn The Things I Want Most: The Extraordinary Story of a Boy's Journey to a Family of His Own Arch Pediatr Adolesc Med, February 1, 2002; 156(2): 193 - 194. [Full Text] [PDF]
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