Answers to questions families often have about caring for their child in foster care

Foster care is a temporary service provided by states to shelter and care for children who cannot live with their families. On any given day in the United States, there are around 500,000 children in foster care. Children in foster care may live with relatives or unrelated foster parents. Temporary placement in foster care may lead to adoption by the foster family (whether related “kin” or not). It may also be a bridge to group homes, residential care facilities, or independent living. Many times, children are reunified with their biological families.

Caregivers should let the primary care clinician know that the child is currently or was previously in foster care. Work together to maintain continuity of care as possible. Consistent care helps the primary care clinician recognize changes that might be caused by underlying medical, dental, or mental health problems. Caregivers who accompany the foster child can assist the primary care clinician by providing medical records and information about the child's history in addition to describing the immediate problem. Caregivers and caseworkers can provide the medical home with documents that identify the child's custodians (foster parent(s). Because of their multiple risk factors, children in foster care will often benefit from more frequent doctor visits than otherwise healthy children.

Many children are reunited with their parents or families of origin. Before a permanent home is found, though, children in foster care often experience frequent placement changes from one foster family to another. Youth often struggle to develop strong supportive relationships as they move into adulthood. Some children remain in the foster-care system for years and "age out" of foster care at age 18 without a permanent family. Adolescents aging out of the foster care system are at high risk for substance abuse, incarceration, homelessness, and even death in young adulthood. On the other hand, children who are well-integrated into their foster family and community experience fewer negative outcomes and have an overall higher well-being.

Children in foster care often have experienced inconsistent and inadequate care, in-utero exposures to alcohol and other substances, separations from multiple caregivers, domestic violence, and exposure to criminal behavior and life-threatening situations. The Adverse Childhood Experiences (ACE) Study demonstrated that child abuse, neglect, and other circumstances that disrupt the child-parent relationship are significantly associated with many leading causes of adult death, such as strokes, cancer, and heart disease.

Stressful childhood experiences lead to higher rates of depression, suicide, cigarette smoking, diabetes, obesity, hypertension, and alcohol and substance abuse. The risk for instability in foster care and behavior problems is increased for children fostered at a later age and children exposed to maltreatment in their birth family. The risk is further increased when the child is separated from their siblings, and foster parents have limited parenting skills.

Given the many challenges faced by children in foster care, they are more likely to suffer from mental health disorders, developmental delays, malnutrition, vision and hearing problems, dental caries (cavities), behavioral problems, lack of trust in caregivers, problems in school, and other medical problems. Foster Care of Children with Special Needs has information for children with complex medical needs.

Adolescents in foster are more likely to engage in high-risk behaviors, which may lead to injury, sexually transmitted diseases, and trouble with the law. Youth living in foster care are also more likely to identify as LGBTQ (lesbian, gay, bisexual, transgender, and questioning); compared with heterosexual youth in foster care and youth in stable housing, LGBTQ youth have poorer school functioning, higher substance use, and poorer mental health. These associated outcomes are often improved with appropriate care that is affirming of their gender/sexual orientation. The Transgender and Gender-Diverse Youth (FAQ) has further information.

Untreated conditions often related to traumatic experiences are the most common reasons for foster placements to fail, leading to further disruptions in care, school, and community for the child. Regularly screening for behavioral problems and post-traumatic stress symptoms by either a psychiatrist or the general pediatrician can be helpful to enable caseworkers to intervene in a timely manner. All screenings recommended by the American Academy of Pediatrics should be performed; this is especially important for children in foster care given their increased risk of various medical, dental, and mental health conditions.

Treatment options will depend upon the specific diagnoses but may include treatment for medical, neurodevelopmental, and mental health conditions. Since children in foster care are often very sensitive to transitions and separations, the medical home, caregivers, and caseworkers should work collaboratively to plan for any treatments and transitions, such as placement transitions and transition to adulthood.

The primary care clinician will need to provide information about treatment options and seek consent for treatment from the legal custodians (typically the birth parents or family of origin).

Welcoming a child in foster care into a family can be wonderfully beneficial for the child and foster family. However, this transition typically does not come without stress. Families will need to work with the child to help them feel welcome, maintain routines, and access needed services while providing a stable and predictable family environment. The extra time needed to care for the child in foster care may create jealousy or other issues among siblings. The entire family may benefit from participating together in activities from recreation to counseling.

Once a child is welcomed into a foster family, it is helpful to make an appointment with the primary care provider to discuss the prior medical care and current medical needs of the child. They may need to be caught up on missed well-child visits, immunizations, and screenings. Also, they are at risk for additional medical, dental, and mental health problems from changes in living situations and traumatic experiences.

The caseworker for a child in foster care can help the foster family access medical records and get in touch with the child's primary care clinician and other medical providers. If it is not practical to stay with the same doctors, then new prescriptions and medical files need to be transferred.

The child's caseworker can help the family find medical and mental health providers that accept Medicaid. Additionally, support groups may help families learn strategies to address common behavior challenges. In some states, there are also programs such as KEEP (Keeping Families Supported), which provide support and parenting skill enhancement to promote child well-being and prevent placement breakdowns. Foster parents that suspect substance use should talk to the child's caseworker and primary care clinician about screening, treatment, and support groups.

Alcohol exposure before birth can lead to fetal alcohol syndrome, birth defects, and/or developmental delays. The Fetal Alcohol Spectrum Disorders (FAQ) provides further details.

Smoking during pregnancy can increase the risk of low-birth weight, and children exposed to second-hand smoke are at increased risk for developing asthma. Marijuana use in pregnancy, depending upon the frequency of use, can cause low-birth weight. Cocaine use in pregnancy can increase the risk for low birth weight and premature births. Opioid (heroin, methadone, oxycodone, hydrocodone, fentanyl, etc.) use throughout pregnancy and particularly when used consistently within the weeks leading up to delivery can result in neonatal abstinence syndrome or opioid withdrawal once the infant is born.

For all addictive substances, the patterns of use may result in poor nutrition, improper weight gain, altered sleep patterns, and increased stress in pregnancy, which may increase the risk of low-birth weight and premature birth. Premature and small infants are at greater risk of medical complications and developmental delays. Answers to questions about premature infants can be found at Premature Infant Follow-Up (FAQ).

Substance abuse by the mother often places the infant at risk for impaired maternal-child bonding and traumatic situations such as neglect and abuse. See Neonatal Opioid Withdrawal Syndrome (NOWS).