Foster Care Placement Improves Children's Functioning FREE

THE 1999 US estimates indicate that 547 000 children are in foster care nationwide,¹ a 35% increase from 1990 estimates of 405 743 foster children,¹ and a 125% increase from the estimate of 243 000 in 1982.² A cross-sectional count of children in foster care in March 1999 identified that 83% of the children remained in care for 6 months or longer with an average length of stay of 33 months.¹

These children enter the foster care system with a high frequency of physical and mental health, developmental, and educational problems, many with problems in multiple domains.^3- 22 Current estimates of children presenting with chronic health problems range from 35% to 80%, and those with mental health problems constitute anywhere from 35% to 95% of the foster care population.^{5,11- 12,15- 16,18,20,22} Developmental, emotional, and/or behavioral problems^11,17- 18 have been diagnosed in up to 84% of foster children, and 31% to 67% have educational problems,^{4- 6,13,18,21} including those receiving special education services (11%-37%)^4,6,13 or more generally functioning below grade level (23%-67%).^4,13,21

Further, there has been considerable evidence implicating the foster care system for inadequate and uncoordinated provision of health, mental health, developmental, and educational services for the many children in need of these services,^{2,5,10- 12,23- 30} although for children who have been maltreated this provision may, nevertheless, be an improvement over their previous receipt of care.^31- 32 However, there has been little examination of the consequences of the foster care experience itself on a child's health or functioning. One characteristic of foster care, length of time in placement, has been the focus of study for some time, but not in association with foster children's well-being. There have been many descriptive studies identifying the amount of time children have resided in foster care and the number of placements they have experienced,^33- 38 as well as studies examining the association between the time children are in foster care with the reasons for their initial placement and other predictor variables, and with dispositional status.^{33- 35,39- 40} Not only do these studies fail to examine other important outcomes for foster children, many are problematic because of their cross-sectional nature,^34- 35,40 which biases their estimates of duration of care,^2,41 and others are dated, limiting their applicability.

Findings from the Fanshel and Shinn⁴² longitudinal examination of the effect of the foster care experience on a child's functioning found that extended time in foster care was associated with significant improvement in academic achievement and gains in IQ. The Fanshel and Shinn⁴² results are echoed by several other investigators. Maluccio and Fein⁴³ in a review of long-term follow-up studies of children who had been in foster care, concluded that children who had been in foster care functioned similarly to their peers in the general population. In a 1999 review, Minty⁴⁴ likewise concluded that outcomes after foster care placements may be better than professional opinion might suggest. However, the available data are scant, particularly for public policy purposes. Unfortunately, many of the studies cited in these reviews are decades old, have usually restricted the children they examine to those who are long-term residents in foster care, and rarely include very young children.

Given the scarcity of longitudinal data available for children in foster care, this study examines the baseline, 6-, and 12-month functioning scores for a cohort of young children enrolled in foster care. Specifically, this research examines changes in functioning as reported by foster mothers during the time children resided in foster care and baseline characteristics, including physical and mental health problems as well as receipt of services for those problems, which are potentially related to changes in reported functioning.

From February 1, 1992, through July 31, 1993, 100% of young children (aged 11-74 months) entering foster care in one administrative region in Connecticut were enrolled in this study. These children represent the entire population of young children eligible for foster care since Connecticut, unlike many states, had no private agency foster placements. By sampling design, children were selected for whom this was the first episode of substitute care, although, by the time they were evaluated for this study, some children had lived in more than one foster care home. All children placed in care through the Waterbury office of the Department of Children and Families and living in the Waterbury area were assessed at a community-based multidisciplinary clinic, the Foster Care Clinic (FCC). Within 60 days of placement, 92% of these children received a baseline health, mental health, and developmental assessment in the FCC (n = 62; 53 [or 85.5%] were seen at the FCC at ≤30 days). The FCC visit consisted of an interview with the foster parent, usually the foster mother, as well as a complete medical examination; developmental, psychological, and speech and language assessments; and motor skill evaluation. The examinations were completed by providers from community agencies and referrals for services were made back to these agencies. The payment for this comprehensive evaluation was generated through Medicaid.

During the same 18-month time frame, all young children (aged 11-74 months) placed into substitute care in the same region but through the Danbury-Torrington office of the Department of Children and Families were also enrolled in the study (n = 58). The foster parents of these children received the same interview as the foster parents of the children placed through the Waterbury office, administered by trained interviewers within their homes rather than at the FCC, and children were assessed for the same developmental, psychological, speech and language, and motor skills using the same battery of instruments employed in the FCC. Fifty (86%) of the Danbury-Torrington families and children were evaluated using the FCC instruments within 60 days of placement. The results of these assessments were not provided to either the children's social services workers or their medical providers. Foster parents and social workers were asked about any medical, psychological, and developmental services these children had received while in foster care and, subsequently, records were obtained by project staff from the office and/or agency where children had received care for each encounter. These services were part of the customary care received by children in foster care and were not the result of the study's assessment procedures.

All children were followed up at 6- and 12-months after baseline. Follow-up rates with both foster parents and biological parents for reunified children were excellent with 57 (92%) of the Waterbury-based children and 53 (91%) of the Danbury-Torrington children followed up at 6 months and 56 (90%) of the Waterbury and 54 (93%) of the Danbury-Torrington children followed up at 12 months. All study procedures were approved by the Human Investigation Committee of the Yale University School of Medicine, New Haven, Conn.

The contents of the baseline, 6-, and 12-month assessments are listed in Table 1. The Department of Children and Families' intake forms supplied information on the demographics of the child, the child's family of origin, reason for placement, and other social services history. In Connecticut, children can be placed in foster care because of substantiated neglect or abuse. Additionally, they can be placed because they are at imminent risk for abuse and neglect. According to the Department of Children and Families, being at risk for abuse and neglect is defined as no hard evidence of abuse or neglect but the presence of some factor in the environment (eg, substance abuse) that greatly increases the likelihood of abuse and neglect. The foster parent interview collected demographic information on the foster family, a measure of the child's mental health,and scores or ratings on the Child Behavior Checklist,^45- 46 the Family Environment Scale,⁴⁷ and the home survey of the Early Screening Profiles (ESP) of the child included the ESP for development and gross and fine motor skills,⁴⁸ the Peabody Picture Vocabulary Test–Revised for language,⁴⁹and a measure of adaptive functioning, the Vineland Adaptive Behavior Scales (VABSs).⁵⁰

The ESPs, published by the American Guidance Service, is a compilation of items from very well-known instruments, the Kaufman Assessment Battery for Children (KABC), the Home Observation for Measurement of the Environment (HOME), and Bruininks-Oseretsky Test of Motor Proficiency. It is a nationally normed screened battery for young children (aged 2-7 years) that is easy to administer, requires only 30 minutes to complete, and correlates well with similar instruments.⁴⁸ It was developed to distinguish children who are potentially at risk for developmental and educational problems from those who are not and to assist in planning any further diagnostic assessments that might be necessary. Available data suggest excellent internal consistency of the various subscales (0.89-0.95), with the exception of the motor subscale, which ranges from 0.60 to 0.78. Test-retest reliability of profile and subscale standard scores are all above 0.80 with the exception of motor, which is 0.70. Interrater reliability for the various subscales ranged from 0.80 to 0.99. Looking at the concurrent validity of the battery, the cognitive language profile correlates 0.84 with the Stanford-Binet Intelligence test composite score, 0.83 with the KABC standard score for achievement, and 0.62 with the Battelle Developmental Inventory Screening Test total score. There were moderate correlations between the Motor Profile and the Bruininks-Oseretsky Test of Motor Proficiency (0.66 with battery standard score). In general, when compared with measures of achievement, the correlations are moderate to high.⁴⁸

The VABS is a measure of current adaptive behavior, which is broadly defined as meeting age and culturally appropriate standards of personal independence and social sufficiency. It is developmental in nature and increases in complexity as a function of age (age range, birth to 18 years 11 months). Recently, attention has been focused on adaptive behavior as a dimension of functioning that may be particularly helpful in differentiating psychologically disturbed children from normal peers.⁵⁰ Given the adaptations required of a child in foster care, this measure may be a crucial factor in a successful foster placement and, consequently, 12-month VABS scores served as the outcome of interest for these analyses. We did not use the entire VABS because of its length but rather a subset of this instrument, which was developed in conjunction with the Yale Child Epidemiologic Catchment Area Methodologic Project. This subset of items correlates well with the entire VABS (≥0.90 on each domain or the composite scale) and has been used with other samples of vulnerable children.^51- 52

Children's physical health status was assessed through data gathered in the FCC or through reports from community physicians in the Danbury-Torrington area. Specific information was collected on the child's height, weight, immunization status, presence of chronic health problems, unresolved acute conditions, hemoglobin level, tetanus titer, and lead level. Tetanus titers were obtained when there was no information available about prior immunizations.

All data analyses were completed using SAS Version 6.12 (SAS Inc, Cary, NC). Following a careful review of these data to identify any out-of-range values or inconsistencies, all standardized scales were constructed according to the scoring directions. Once data management tasks were completed, all univariable and bivariable analyses were done to characterize the children's experiences prior to coming into foster care and to examine the interrelationships among developmental, behavioral, and physical health.

The form of a particular bivariable analysis was dictated by the structure of the variables being compared. For continuous outcome variables, correlations and regression analyses were used. A multivariate linear regression model was developed to predict the main outcome of interest, 12-month VABS score.

Table 2 lists the baseline sociodemographic, social services, and developmental, physical, and mental health characteristics of the study children. Children ranged in age from 11 to 76 months and were evenly divided by sex. Children were most often placed because they were at risk for abuse (58 children [48.3%]) and, within this first episode of foster care, most children were in the foster home they were originally placed in (97 children [80.8%]). As with most cohorts of children in foster care, these children had high rates of medical problems (80 children [66.7%]), had poor language scores (29 children [33.7%] in the 63-80 range on the ESPs), and had significant behavioral issues (23 children [24.2%] in the clinical or subclinical range on the Child Behavior Checklist).

Table 3 displays information on the foster families. Foster mothers most often had at least a high school education (68.3%), were homemakers (50.0%), and were either new (35.0%) or long-term (≥6 years; 37.5%) foster parents.

Table 4 gives the VABS scores over time. At baseline, children had a mean VABS score of 79.5 points signifying functioning below the average range. There were no differences in VABS scores for children who had been in 1 foster home (mean, 79.6 points) vs those who had been in more than 1 foster home (mean, 78.8 points) prior to the initial assessment. By 6 months, we observed an average reported mean change in functioning of 7.87 points and an average score of 86.5 points. By 12 months after entry into foster care, we observed an average reported mean change of an additional 9.65 points and an overall mean functioning of 94.5 points, well within the nationally normed average range.

Table 5 summarizes the results of the multivariate linear model predicting 12-month VABS score. Controlling for baseline VABS score, abuse as a reason for placement, older age at placement, female sex, African American ethnicity, longer time in foster care, and fewer recommended services while in foster care were all statistically significantly related to improved functioning as reported by the foster mother. This model explained 50% of the variance in the 12-month VABS score.

These results demonstrate that children's reported functioning improves over the course of placement in foster care. To determine whether this improvement is simply an artifact of abnormally low scores at baseline because of the trauma of being separated from family, we examined improvement over 2 six-month intervals and improvement for children who had multiple homes during the first episode of foster care prior to the baseline assessment. The first finding of note is that improvement in the first 6 months is similar to that in the second 6 months. The second finding is that children who had more than 1 foster care home prior to the baseline assessment had the same baseline VABS score and were equally likely to increase in reported functioning over the 12-month follow-up compared with children who were in 1 home at the baseline assessment. Further, reported improvement is related to sociodemographic characteristics, specifically age, sex, and ethnicity; reason for placement; number of physical and mental health services received; developmental and educational services recommended at entry into foster care; and length of time in care. These findings are important for several reasons. First, they demonstrate that certain subgroups of children entering foster care may be more likely to show improved functioning over time, namely, those who are older, female, and were abused. Second, they demonstrate that children with greater needs, as approximated by the number of services recommended at baseline, were less likely to improve over time. This finding is consistent with earlier retrospective work showing that children with more developmental, behavioral, and physical health problems at entry into care were more likely to remain in care.¹⁷ The importance of early identification and treatment of children's problems cannot be overstated. The relationship of problems at entry into care with remaining in care and, indeed, improvements in reported functioning while in care argue for early and thorough attention to children's problems. Unfortunately, our time frame was too short (12 months of follow-up) and our sample size was too small to begin to disaggregate the possible benefits for services targeted to the problems children displayed at entry into care.

We were unable to identify with these data whether specific features of the foster care environment, such as an initial attachment to a foster parent, promote growth in functioning. Unfortunately, the variables we had that assessed foster family environments, the HOME Scale on the ESP and the Family Environment Scale, although demonstrating considerable variation across homes, were not related to improvements in reported functioning. We believe a careful look at the foster parent–foster child interactions may provide some insight into the aspects of the foster care environment that promote increases in foster mother–reported functioning.⁵³

Finally, our data argue against reporting bias as an explanation for these increases in reported functioning since children who experienced a change in foster homes continued to increase in the foster mother's reported functioning evaluation. At baseline, children who remained in the same home throughout the 12 months had a VABS score of 79.72 compared with 79.31 for children who eventually changed placements (t = 0.132; P = .90). At 12 months, those who remained in the same home had a mean VABS score of 97.66 and those who changed homes had a mean score of 91.91 (t = 1.14; P = .26). Thus, it does not seem as if the foster mothers whose children remained with them for 12 months were more likely to rate children's functioning as improved at 12 months compared with foster mothers who had known their children for less than 12 months (mean time in placement at the 12-month assessment for those who changed homes = 7.1 months).

As with all research, these results must be viewed in light of their limitations. First, our outcome measure, VABS score, was foster parent–reported and although the VABS score correlated highly with ESP and other interviewer-administered scales, we made no attempt to measure functioning independent of the foster mothers' reports. Second, this is a small sample of young children placed for the first time in foster care in one Connecticut region. The results may not apply to older children, those who have experienced multiple episodes of foster care, or those in other geographic regions. When this study was undertaken, foster care placements, particularly for young children, were unusually stable. Finally, without considerable additional information about the foster care homes these children were placed in, the reasons for the impressive increases in functioning remain unknown.

Regardless of these limitations, the findings lead us to conclude that children's functioning, as reported by their foster mothers, improves while in foster care. Further, understanding the features of the foster care experience most likely to promote improved reported functioning will be critical for the care and development of maltreated children.

Accepted for publication May 16, 2001.

This research was supported in part by award MH48456 from the National Institute of Mental Health, Rockville, Md.

An earlier version of this work was presented at the annual meeting of the Pediatric Academic Societies, Boston, Mass, May 13, 2000.

Children enter foster care with many physical and mental health problems. However, there has been little research on the consequences of the foster care experience for children's functioning.

At entry into foster care, children had a mean functioning score below the average range. At the 12-month follow-up, children showed an average change of almost 10 points, for a mean score well within the nationally normed average range. The multivariate linear model predicting 12-month scores showed many important predictors of increased functioning in addition to baseline functioning. The results argue for a careful examination of the foster care environment to better understand what aspects of the environment contribute to improved functioning.

Corresponding author: Sarah McCue Horwitz, PhD, Department of Epidemiology and Public Health, Yale University School of Medicine, 60 College St, Box 208034, New Haven, CT 06520-8034 (e-mail: patricia.krieger@yale.edu).