Committee on Early Childhood , Adoption and Dependent Care Developmental Issues for Young Children in Foster Care

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 shortand 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. EARLY BRAIN AND CHILD DEVELOPMENT 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 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. PEDIATRICS (ISSN 0031 4005).