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Foster Care
The vast majority of children are placed in foster care as a result of neglect, physical abuse, parental substance abuse or abandonment.[1] Contrary to a prevailing misconception, only approximately 10% of children for whom abuse or neglect is substantiated (approximately one-third of those reported) are removed from parental care. Consequently, children in foster care are a very high-risk group of children and youth. Some children spend a substantial portion of childhood in foster care. For example, an analysis of national data on the characteristics of children in foster care revealed that approximately 37% had been in out-of-home care for 2 years or more, and approximately 12% had been in care for more than 5 years,[2][ while in some large urban centers (eg, Cook County, Illinois) the median duration of placement approached 5 years in 1994 [3]

Many children enter foster care with chronic health, developmental, and psychiatric disorders, reflecting the neglect and abuse experienced before placement in addition to the trauma from being separated from their parents. More disturbing, however, is evidence that their health care is often neglected while in foster care. In 1995, the US General Accounting Office found that young foster children do not receive adequate preventive health care while in placement, many significant problems go undetected, or, if diagnosed, are not evaluated and treated[4] Among other things, this neglect of children’s basic health care needs is a result of inadequacies in the foster care system, as well as inadequacies in the health care system.

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Several efforts have been made to remedy this problem. More than a decade ago the Child Welfare League of America, in collaboration with the American Academy of Pediatrics, published guidelines for health care of foster children[5].[ Child Welfare League of America. 1988] Class action lawsuits in at least 21 states have challenged state agencies to ensure adequate care, including health care, for this very high-risk group[6] With a few notable exceptions, obstacles to delivering adequate care to these children have persisted. The idealistic assumption that removing children from their parents obligates the state to provide exemplary care has seldom materialized. Thus, clinical and research challenges continue for health care providers and others involved in the lives of these children.

Brief History of Foster Care In The United States
Until nearly 150 years ago, families who could not raise their own children relied for help on extended family members, charity from religious organizations, or orphanages. Many older children were apprenticed to tradesmen as a means of preparing them for adulthood.[7][] State-supported foster care in the United States arose in the 19th century from social welfare programs that sent children from Eastern cities to the Midwest, where they lived with farm families as an escape from the dangers of urban life. In 1863, the Massachusetts State Board of Charities approved funding for a system of state-supported foster homes, paying nonrelatives a weekly stipend of $2.00 to care for children in need of out-of-home placement. Federal support for foster care was established in 1933 under Title IV of the Social Security Act. In the 1960s the number of children placed in foster care rose dramatically in response to increased awareness of the problem of child abuse. However, by the late 1970s social service researchers had documented that many children remained adrift in the foster care system because little effort was made to either reunify them with their biological families or arrange for adoptions   [8]

In 1980, the Child Welfare Reform Act (PL 96-272) directed social service agencies to prevent out-of-home placements when possible, to make reasonable efforts to reunify them with their biological families when feasible, or to find adoptive placement when necessary. Although the number of children in foster care initially declined in the early 1980s, increases in the incidence of substance abuse, single-parent families, homelessness, child poverty and child abuse, as well as the emergence of human immunodeficiency virus (HIV) infection, resulted in even greater expansion of the foster care population.[ Curtis 1999] Current efforts to reduce the number of children in foster care include increased use of family preservation programs to prevent out-of-home placement, more attention to returning children home quickly from foster care, accelerating termination of parental rights proceedings, and greater efforts to adopt these children.

The Adoption and Safe Families Act (ASFA) of 1997 is the most significant recent legislation affecting children in foster care. The context for this law was the pervasive view that the pendulum had swung too far to the side of preserving families, and away from protecting children. ASFA establishes the health and safety of children in the child welfare system as clear priorities. Well-justified concern persists regarding the length of time children linger in care; ASFA requires states to begin terminating parental rights if a child has been in care for 15 of the prior 22 months. Under aggravated circumstances, such as when a parent has been convicted of a felony against a child or a parent’s rights to a sibling have been involuntarily terminated, AFSA enables (but does not require) the states to proceed with terminating parental rights without providing further justification for doing so. For all children in foster care, states must obtain a court order at least every 12 months and demonstrate that reasonable efforts have been made toward establishing a permanent plan for reunification, or toward legal guardianship or adoption. The legislation also offers fiscal incentives for states to increase the number of children adopted. Clearly, the intent is to limit foster care drift.

Traditional Versus Kinship Foster Care

Nonrelative care was the norm in foster care until the early 1990s. However, as more women entered the labor force the number of nonrelative foster family homes declined from about 147 000 in 1984 to 100 000 in 1990][9] In response to this trend, public agencies sought assistance from the children’s relatives to provide kinship foster care homes. In current practice, the term kin includes any relative, by blood or marriage, or any person with close ties to the family[10]

Kinship care may offer certain advantages. Children may find placement with known family members less traumatic than placement with strangers. Cultural and religious practices are more likely to be continued, and this has been a major factor for advocates of kinship care. Kin frequently have a special commitment to helping their own (blood is thicker than water). Contact with parents is often more frequent, and may facilitate eventual reunification. There may also be disadvantages to kinship care compared with regular foster care. Skeptics question whether the extended family members of these inadequate parents are appropriate surrogates to provide kinship care.

Although each situation should be individually weighed, it is crucial to ask how kinship care can be helped to succeed given the strong ideological preference for first seeking placement with kin. Potential kinship caregivers must be carefully screened, especially because they are often not required to meet the same standards used for licensed foster homes. Frequently, informal kinship placements (ie, no court involvement and no legal transfer of custody) are arranged by public or private social service agencies, and it is uncertain what services kinship families receive and what obligations the agencies impose under these circumstances. Moreover, we know little of how children fare in these informal arrangements. In most situations involving abuse or neglect, it is probably preferable that care and custody be formally transferred to a social services agency, to enable ongoing support and oversight. On the other hand, we do know that children in kinship care have needs similar to those in nonrelative foster care, especially regarding their mental and dental health. We also know that kinship caregivers tend to be older, less educated, less financially stable, and in poorer health than nonrelative foster parents.[11][

Proponents of kinship care believe kin will/should provide for their own; but these families have typically received fewer services, even when the public agency has had legal custody. Therefore, because children in kinship and traditional foster care face similar conditions, in terms of reasons for their placement, their levels of health, mental health and developmental needs, and financial difficulties confronting many of the families who provide such care, more uniform approaches are necessary with respect to placement and support of all children in care, regardless of type of placement. Furthermore, children in kinship care have averaged longer stays than those in nonrelative foster care, largely because less vigorous efforts have been made to reunify them with their parents and to determine a permanency plan. Again, it is incorrect to assume that because the child is with family there is little urgency to return him or her to the biological parents. All children in foster care need secure arrangements, and careful long-term planning is needed to reduce the uncertainties in their lives.

Health and Mental Health of Children in Foster Care
For nearly 3 decades, researchers have noted a high prevalence of health and mental health problems in foster children. In 1972 and 1973 Kavaler and Swire[12][] systematically studied the health status of 668 children 0 to 15 years old who had been in foster care in New York City for at least 1 year. Approximately half (45%) of the children had 1 or more chronic medical problems and more than a third (37%) required a referral to a specialist for further evaluation and treatment. Nearly one-third (29%) of the preschool children were suspected of having delayed development and more than half (55%) of the school-aged children were suspected of having borderline or retarded mental development. Moderate to severe mental health problems were noted in approximately 70% of the children. Since then, cross-sectional surveys of children living in different cities or regions of the country,[13][] statewide population-based studies[14][   and a multicity comparison study[US General Accounting Office. Foster Care: Health Needs of Many Young Children Are Unknown and Unmet. Washington, DC: US General Accounting Office; 1995] have confirmed Kavaler and Swire’s initial observations.

The findings of consistently high rates of physical, mental health, and development problems in this population raise several important questions. To what extent did children bring these problems with them into foster care? To what degree are these (or additional) problems attributable to the foster care experience? Does the foster care system attend to the special needs of these children and help to improve their health status and overall functioning? This study will attempt to answer these questions.

This study will be designed as a descriptive, correlational study using prospective data collection.  The intent of this research will be not to explain or to presume the underlying causes for any relationship among the variables of interest.

Research Questions
Research question are as follows:

1.      What and why is foster care needed?

2.       What is the U.S. governments plan to improve the number of children being placed in foster care as a result of their parents, who are addicted to ?

3.       Why are there an overwhelming percentage of African American children in Foster Care as a result of substance abuse?

4.       What is the long term impact of a addicted infant placed in a foster home.

5.       How is the child welfare system and substance abuse treatment developed to assist permanency within families affected by ?

Why is this study important?
This study is important because there is a paucity of research done in the area of what makes for effective foster care. The results of this study will be of interest to social workers, governmental agencies, and foster parents and can be used to improve foster care.

Methodology and Procedures

The heads of 50 foster home agencies in the Western part of the U.S. were selected for this study:  Questionnaires consisted of 30 questions  in which the participants were asked to rate on a scale of 1 to 10 with 1 being favorable and 10 unfavorable, their opinions of the effectiveness of the foster care agencies  in the following areas: meeting the physical and mental health needs of foster care children; dealing with foster care children born addicted to drugs; dealing with the needs of ethnical minority children; and cooperation with governmental and other social service agencies;    Data was gathered over a one-year period.

Questionnaires will be completed at each subject’s convenience in a naturalistic setting of their choice.  Thus, subjects could complete questionnaires in the unit in which they worked their home, or any other setting of their choice.  The questionnaire packets will include six items.  Those documents will be (a) a cover letter describing the study, (b) two informed consent forms, (c) a questionnaire gathering information about the foster care agency, for example, its size, types of cases handled, community characteristics, etc., (d) abovementioned questionnaire, (e) a stamped, self-addressed, large manila envelope in which the two completed questionnaires were place, and (f) a stamped, self-addressed, legal-size white envelope for the signed informed consent form.  The envelopes will be then be placed in first class mail for return to the PI.  Sample

Participation in the study will be voluntary; and the completion of the returned, completed surveys will be voluntary; and the returned, completed surveys will serve as each participant’s consent.  The informed consent form will be placed in a sealed envelope by subjects and included in the manila envelope, which contained the completed questionnaires.  All informed consent forms remained in the sealed envelopes, separate from the questionnaires, and were kept in a locked file drawer accessible only the principal investigator (PI) in the investigator’s home.

The PI for questionnaire will be provided a stamped, self-addressed envelope.  Participant confidentiality will be maintained.  No names, dates, or any identifying information concerning the subjects will be collected on any data collected on any data collection forms.  All questionnaires will be number coded by the PI to assure confidentiality and to maintain complete data sets for each subject.

Analytical Software and Statistical Package for the Social Sciences PC+ will be used in the data analysis of this study.  Responses will be entered into the computer using alphanumerics.  Missing data will be coded using the letter M or the numeral 9.  The entries will bee verified with the original questionnaires and checked for outliers and codes that were not consistent with code designations.  A consistency check will be performed.  Descriptive measures will be used to tabulate agency data.  The significance chosen for this study was ?0.05.

Frequency distributions and descriptive statistics were calculated to develop a profile of the agencies.  Mean, median, and mode were calculated for the size of the foster agency and location (rural, metropolitan, or suburban)…  Correlation statistics were calculated to demonstrate relationships between the size of the foster agency, and the effectiveness of the agency in serving the needs of its clients.

Analysis of variance (ANOVA) was used to compare subjects on selected variables.  The Conferring statistic was used to test the significance of perceived level of satisfaction with the services of the foster agency psychiatrists.

Conclusions
Unfortunately, the population of children in foster care has increased dramatically over the past 2 decades.  Because of the circumstances that lead to placement, children entering the foster care system often have serious health and mental health disorders.  Many of the children spend a significant portion of their childhood in foster care and there is little evidence that they receive comprehensive health care while in placement.  In many respects, foster care remains a poor system for poor children.  However, placement in foster care provides an opportunity and a responsibility to address all of the health care needs of this very high-risk group of children.  Health care practitioners and social workers can play a significant role in providing care and assisting foster parents to ensure that children receive appropriate services in a timely fashion.  Researchers can examine promising strategies for achieving these goals.

References

Berrick JD, Barth RP, Needell B, (1994) A comparison of kinship foster homes and foster family homes: implications for kinship foster care as family preservation. Child Youth Serv Rev.;16:33-63

Chernoff R, Coombs-Orme T, Risley-Curtiss C, Heisler . (1994). Assessing the health status of children entering foster care. Pediatrics;93: 594-601

Child Welfare League of America. Standards for Health Care Services for Children in Out-of-Home Care. Washington, DC: Child Welfare League of America; 1988

Dubowitz H, Feigelman S, Harrington D, Starr R, Zuravin S, Sawyer R. (1994); Children in kinship care: how do they fare? Child Youth Serv Rev. 16:85-106

Dubowitz H, Feigelman S, Zuravin S, Tepper V, Davidson N, Lichenstein R. (1992).The physical health of children in kinship care. Am J Dis Child.;146:603-610

Dubowitz H, Zuravin S, Starr RH, Feigelman S, Harrington D. (1993); Behavior problems of children in kinship care,. J Der Behav Pediatr. 14:386-393

Fanshel D, Shinn EB. Children in Foster Care: A Longitudinal Investigation. New York, NY: Columbia University Press; 1978

Goerge RM, Wulczyn F, Harden A. Faster care dynamics. In: Curtis PA, Dale G Jr, Kendall JC, eds. The Foster Care Crisis: Translating Research Into Policy and Practice. Lincoln, NE: University of Nebraska Press; 1999:17-44. Chap

Gruber AR. Children in Foster Care. New York, NY: Human Sciences Press; 1978

Halfon N, Berkowitz G, Klee L  (n.d.) Children in foster care in California: an examination of Medicaid reimbursed health services utilization. Pediatrics. 19

Hochstadt N, Jaudes P, Zino D, Schacter J.( 1987) The medical and psychosocial needs of children entering foster care. Child Abuse Negl.; 2:53-62

Kavaler F, Swire MR. Foster Child Health Care, Lexington, MA: Lexington Books; 1983

Klee L, Kronstadt D, Zlotnick C. (1997) Foster care’s youngest: a preliminary report. Am J Orthopsychiatry. 67:290-299

National Commission of Family Foster Care(1991). A Blueprint for Fostering Infants, Children, and Youth in the 1990s. Washington, DC: Child Welfare League of America;

Pear R, Many states fail to meet mandates on child welfare. New York Times. 1, 14. March 17, 2000

Schor E. L.. (1982). The foster care system and health status of foster children. Pediatrics.;69:521-528

Simms M. D. (2989);The Foster Care Clinic: a community program to identify treatment needs of children in foster care. J Dev Behav Pediatr. 10:121-128

Takas M. (1993) Kinship care: developing a safe and effective framework for protective placement of children with relatives. Zero to Three  13:12-17]

Takayama J. I., Wolfe E., and Coulter K. P. (1998).Relationship between reason for placement and medical findings among children in foster care. Pediatrics. 101:201-207

Tatara T. Characteristics of Children in Substitute and Adoptive Care–A Statistical Summary of the VCIS National Child Welfare Data Base. (VCIS Research Notes No. 3, 1-4). Washington, DC: American Public Welfare Association; 1992

Trattner W. I.. From Poor Law to Welfare State. 4th ed. New York, NY: Free Press; 1989

US General Accounting Office. Foster Care: Health Needs of Many Young Children Are Unknown and Unmet. Washington, DC: US General Accounting Office; 1995

[1] Klee L, Kronstadt D, Zlotnick C. Foster care’s youngest: a preliminary report. Am J Orthopsychiatry. 1997;67:290-299
[2] Tatara T. Characteristics of Children in Substitute and Adoptive Care–A Statistical Summary of the VCIS National Child Welfare Data Base. (VCIS Research Notes No. 3, 1-4). Washington, DC: American Public Welfare Association; 1992
[3] Goerge RM, Wulczyn F, Harden A. Faster care dynamics. In: Curtis PA, Dale G Jr, Kendall JC, eds. The Foster Care Crisis: Translating Research Into Policy and Practice. Lincoln, NE: University of Nebraska Press; 1999:17-44. Chap
[4] US General Accounting Office. Foster Care: Health Needs of Many Young Children Are Unknown and Unmet. Washington, DC: US General Accounting Office; 1995
[5] Child Welfare League of America. Standards for Health Care Services for Children in Out-of-Home Care. Washington, DC: Child Welfare League of America; 1988
[6] Pear R, Many states fail to meet mandates on child welfare. New York Times. 1996:1, 14. March 17, 2000
[7] Trattner WI. From Poor Law to Welfare State. 4th ed. New York, NY: Free Press; 1989
[8] Fanshel D, Shinn EB. Children in Foster Care: A Longitudinal Investigation. New York, NY: Columbia University Press; 1978 Gruber AR. Children in Foster Care. New York, NY: Human Sciences Press; 1978

[9] .[ National Commission of Family Foster Care. A Blueprint for Fostering Infants, Children, and Youth in the 1990s. Washington, DC: Child Welfare League of America; 1991
[10] .[ Takas M. Kinship care: developing a safe and effective framework for protective placement of children with relatives. Zero to Three. 1993; 13:12-17]
[11] Dubowitz H, Feigelman S, Harrington D, Starr R, Zuravin S, Sawyer R. Children in kinship care: how do they fare? Child Youth Serv Rev. 1994;16:85-106

Berrick JD, Barth RP, Needell B, A comparison of kinship foster homes and foster family homes: implications for kinship foster care as family preservation. Child Youth Serv Rev. 1994;16:33-63
[12] Kavaler F, Swire MR. Foster Child Health Care, Lexington, MA: Lexington Books; 1983
[13] Schor EL. The foster care system and health status of foster children. Pediatrics. 1982;69:521-528 [20.] Simms MD. The Foster Care Clinic: a community program to identify treatment needs of children in foster care. J Dev Behav Pediatr. 1989;10:121-128

Chernoff R, Coombs-Orme T, Risley-Curtiss C, Heisler A. Assessing the health status of children entering foster care. Pediatrics. 1994;93: 594-601

Dubowitz H, Feigelman S, Zuravin S, Tepper V, Davidson N, Lichenstein R. The physical health of children in kinship care. Am J Dis Child. 1992;146:603-610

14Dubowitz H, Zuravin S, Starr RH, Feigelman S, Harrington D. Behavior problems of children in kinship care,. J Der Behav Pediatr. 1993; 14:386-393

Hochstadt N, Jaudes P, Zino D, Schacter J. The medical and psychosocial needs of children entering foster care. Child Abuse Negl. 1987; 2:53-62

Takayama JI, Wolfe E, Coulter KP. Relationship between reason for placement and medical findings among children in foster care. Pediatrics. 1998;101:201-207
[14] Halfon N, Berkowitz G, Klee L. Children in foster care in California: an examination of Medicaid reimbursed health services utilization. Pediatrics. 1992;89:1230-1237

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