The Effects of Foster Care Placement on Young Children’s Mental Health

Introduction Young children are more likely than older children to be placed in foster care and to spend a larger proportion of their life in the foster care system (Goerge & Wulczyn, 1998). In a recent review of foster care in several states, the incidence of placement in foster care for children under age 5 was double that of children aged 5–17 (4 per 1,000 vs. 2 per 1,000) (Goerge & Wulczyn, 1998). Young children are in foster care longer than older children and infants are in foster care significantly longer than other age groups (Goerge & Wulczyn, 1998). In the 5 states studied, the median length of time infants spent in foster care ranged from 11 to 42 months (Goerge & Wulczyn, 1998). This paper explores the potential impact of foster care placement on young children’s attachment relationships and mental health. Factors Leading to Placement in Foster Care Children are removed from their homes to protect them from immediate physical harm (Zuravin & DePanfilis, 1997). Substance abuse and the drug culture account for the majority of young children placed in foster care (Simms, 1991). Race and socioeconomic status does not appear to have a major impact on decision making regarding foster care placement (Zuravin & DePanfilis, 1997). In general, foster care placement adequately provides for the physical protection of children. For example, in a study comparing home and out-of-home placements of infants born to substance-abusing mothers, there was a 7% death rate and a 4% rate of abuse and neglect in the home placements compared to none of these events in the infants placed in kinship or foster care placements (Tyler, Howard, Espinosa, & Doakes, 1997). However, foster care placement has implications for the healthy emotional development of young children. Attachment Disruptions Among Young Children in Foster Care Out-of-home placement is typically associated with numerous disruptions in attachment relationships. These losses and lack of permanence undermine a child’s attempt to form a secure attachment with a primary caregiver. The more changes in caregivers young children in foster care experience the more likely they are to exhibit oppositional behavior, crying, and clinging (Gean, Gillmore, & Dowler, 1985). Disruptions in attachment relationships can lead to Reactive Attachment Disorder of Infancy or Early Childhood (American Psychiatric Association, 1994), a disorder in which the child exhibits severe disturbances in relationships with caregivers. The importance of the relationships foster children develop with their foster parents is sometimes underappreciated. Psychiatric emergencies among children in foster care are often precipitated by disruptions in their attachment relationships with foster parents (Pilowsky & Kates, 1996). Infants placed in outof-home care for several months will come to view the caregiver who provides for their daily emotional and physical needs as their attachment figure. When working with infants in out-of-home placements, it is important to keep in mind that, unless the out-of-home placement is very brief, reunification with parents or placement in an adoptive home constitutes an attachment disruption. Reducing Attachment Disruptions In order to reduce attachment disruptions for infants, there has been an increasing emphasis on allowing infants to stay with their mothers despite the mother’s difficulties. For example, allowing babies to stay with incarcerated mothers (Harris, 1992) or mothers in residential treatment for substance abuse (Wobie, Eyler, Conlan, Clarke, & Behnke, 1997). Ideally, these programs not only reduce attachment disruptions but allow close supervision of the mother and infant and the opportunity for interventions to enhance the quality of the motherchild interaction. In an attempt to expedite placement with a consistent caregiver, concurrent planning has been promoted as a useful tool. Development of concurrent plans, when a child is in foster care, allow efforts to reunify children with their biological parents to take place simultaneously with efforts to achieve an alternative plan. Concurrent planning is one feature of the Adoption and Safe Families Act (ASFA) which was passed in 1997. An additional feature of ASFA is that the length of time for the biological parents to make significant progress on the goals outlined by the reunification plan is limited to twelve months, though judges can make exceptions. Both policies have the potential to reduce the attachment disruptions experienced by young children in out-of-home placements. Concurrent planning has the potential to limit the attachment disruptions faced by infants placed in substitute care. By placing the child in the home of a foster family or family member who could become the child’s adoptive family if the biological parent fails to regain custody, further disruption of attachment relationships is prevented if the child is unable to be reunified with biological parents. Concurrent planning does not eliminate the stress that attachment disruptions cause babies and toddlers. However, it may limit the extent of the disruption by reducing the number of disruptions the child experiences. According to ASFA guidelines, if biological parents have failed to make significant progress toward reunification at the end of twelve months, a petition to terminate parental rights can be filed. This time limit serves the ultimate goal to reunify child and biological parents within a timely manner. If the biological family is unable to make the changes needed to provide adequate care by this deadline, then the child may obtain permanency by remaining with the current caregiver for the purpose of adoption. This time limit is more congruent with a child’s sense of time and a child’s need for a stable, continuous relationship with a caregiver. There are a number of issues with the application of concurrent planning that have not been resolved. For the attachment needs of infants, concurrent planning is clearly superior to the current system as it has the potential to reduce the number of attachment disruptions experienced by the child. For caregivers, however, the loyalty conflicts inherent in the plan have the potential to create friction between substitute caregivers and the biological parents. Although time limits are responsive to the child’s sense of time, this deadline creates additional stress for parents seeking to resolve the difficulties that lead to their child’s placement in foster care. It is unclear whether concurrent planning and the new time limits will affect quality of care. It is possible that concurrent planning may indirectly have a positive effect on the quality of care children receive in foster care. The possibility that foster parents may adopt the child may increase their emotional investment in the child, enhancing the quality of care. However, there is also the possibility that reduced time lines in ASFA may lead to premature reunification with parents in order to avoid termination of parental rights, indirectly causing a negative effect on quality of care. Maintaining Attachment Relationships with Parents While in Foster Care One of the biggest challenges faced by young children in foster care is maintaining attachment relationships with their parents. Children and parents need the opportunity to maintain an attachment relationship and develop more positive interactions. However, visits with parents can be upsetting to young children in foster care and disruptive to other aspects of their development (Gean, et al., 1985). The majority of young children who visit their biological parents in the parents’ home exhibit symptoms (toileting problems, sleep disturbance, aggressive behavior, clinging, and crying) before, during, and/or after these visits (Gean, et al., 1985). This difficulty in maintaining a relationship with a non-primary caregiver is not specific to foster care. Infants of separated and divorced couples who have overnight visits with their fathers are more likely to have insecure attachment relationships with their mothers (Solomon & George, 1999). However, the overnight visits do not lead to improved attachment relationships with their fathers (Solomon & George, 1999). In both studies (Gean et al., 1985; Solomon & George, 1999), the attitude of the primary caregiver (foster parent or mother) towards visitation affected the infant’s adjustment to visitation. Thus, it may be that having to place the infant in a situation the caregiver is uncomfortable with undermines the caregiver-child relationship. Risk of Unresponsive Care in Foster Care Care that provides for the infant’s basic physical needs but is relatively insensitive or unresponsive to the infant’s attachment signals and emotional needs can lead to an insecure infant-caregiver attachment (Ainsworth, Blehar, Waters, & Wall, 1978; De Wolff & van Ijzendoorn, 1997). Although early insecure attachment relationships are not pathological, they place children at risk for subsequent emotional and interpersonal difficulties (Carlson, 1998; Erickson, Sroufe, & Egeland, 1985; Lyons-Ruth, Alpern, & Repacholi, 1993; Lyons-Ruth, Easterbrooks, & Cibelli, 1997). Among infants placed in foster care at less than a year of age, the nature of the infant-foster mother relationship is a reflection of the foster mother’s attachment style (Stovall & Dozier, 1998). That is, sensitive foster mothers provide responsive care that leads to a secure attachment relationship with their foster infant. Conversely, with toddler placements, the child-foster mother relationship reflects the child’s previous attachment experiences (Stovall & Dozier, 1998). Thus, toddlers placed in out-of-home care after experiencing neglect, abuse, and/or unresponsive care actually need more responsive care than typical toddlers in order to develop a secure attachment. The type of out-of-home placement most likely to interfere with the development of healthy attachment in infants and toddlers is placement in a group care setting. During the 1930s and 1940s, there were detailed observations of the deleterious effects of group care on the physical and emotional health of young children (Freud & Burlingham, 1944; Spitz, 1945). Although the events of the 1980s and 1990s have been less dramatic than the events leading to the out-of-home placement of children in the 1930s and 1940s, the number of "displaced" children has again led to the placement of young children in group care settings. Thirteen to eighteen percent of children placed in group settings in California from 1988 to 1995 were under age six (Berrick, et al., 1998). The minimum staffing ratio for infants in California group care is one adult to ten infants and there is a high staff turnover rate (Berrick, et al., 1998). Thus, it seems highly unlikely that babies placed in group care will receive consistent, responsive care in these settings and make good attachments. Improving the Responsiveness of Foster Care Foster parents may need guidance in how to effectively respond to the special attachment needs of infants and toddlers in their care (Stovall & Dozier, 1998). The more opportunities foster parents have to make decisions about the child’s needs (e.g., how to reduce distress associated with visitation), the more likely they will feel confident in their abilities to provide a secure base for the child in their care. In addition, foster parents may need concrete support such as day care or respite care that helps them have the energy needed to respond to the attachment needs of young at-risk children. Day care or respite care should be brief and predictable in order to minimize attachment disruptions. When a young child’s previous experiences in relationships make it difficult for him to communicate his needs to a caregiver, it may also be necessary for a play therapist to work directly with the child. When it is necessary to place infants in group care, the care should simulate, as much as possible, the type of care infants receive in a family setting. Caregivers should be assigned to particular infants rather than to particular tasks. The group care should be organized such that caregivers have the time and flexibility to learn the infant’s attachment needs and communications and respond to them. Conclusions Safeguarding the physical safety of infants and toddlers in foster care is not enough. Although there are no easy solutions, it is important that we address the mental health needs of young children in foster care. Both the child’s need for continuity of relationships and his need for sensitive, responsive care should be considered in foster care placement decisions. When it is necessary for the child to experience an attachment disruption, we need to maximize the possibility of him experiencing sensitive, responsive care with the alternative caregiver. Beth Troutman, Ph.D. is Assistant Professor of Clinical Psychiatry at the University of Iowa Hospitals and Clinics; Susan Ryan, M.A. is a Doctoral Candidate in the School Psychology Program at the University of Iowa; and Michelle Cardi, M.A., is a Research Assistant at the University of Iowa Hospitals and Clinics. All are located in Iowa City, Iowa. References Ainsworth, M., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale, NJ: Erlbaum. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, DSM-IV. Washington, DC: American Psychiatry Association. Berrick, J., Needell, B., Barth, R., & Jonson-Reid, M. (1998). The Tender Years. Oxford: Oxford University Press. Carlson, E. (1998). A prospective longitudinal study of attachment disorganization/disorientation. Child Development, 69, 1107-1128. De Wolff, M., & van Ijzendoorn, M. (1997). Sensitivity and attachment: A metaanalysis on parental antecedents of infant attachment. Child Development, 68, 571-591. Erickson, M., Sroufe, A., & Egeland, B. (1985). The relationship between quality of attachment and behavior problems in preschool in a high-risk sample. In I. Bretherton and E. Waters (Eds.). Growing points of attachment theory and research. Monographs of the Society for Research in Child Development, 50, 147-166. Freud, A., & Burlingham, D. (1944). Infants without families. New York: International Universities Press. Gean, M., Gillmore, J., & Dowler, J. (1985). Infants and toddlers in supervised custody: A pilot study for visitation. Journal of the American Academy of Child Psychiatry, 24, 5, 608-612. Goerge, R., & Wulczyn, F. (1998). Placement experiences of the youngest foster care population: Findings from the multistate foster care data archive. Zero to Three, 19(3), 8-13. Harris, J. (1992). Babies in prison. Zero to Three, 13, 17-21. Lyons-Ruth, K., Alpern, L., & Repacholi, B. (1993). Disorganized infant attachment classification and maternal psychosocial problems as predictors of hostile-aggressive behavior in the preschool classroom. Child Development, 64, 572-585. Pilowsky, D., & Kate, W. (1996). Foster children in acute crisis: Assessing critical aspects of attachment. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1095-1097. Simms, M. (1991). Foster children and the foster care system, part II: Impact on the child. Current Problems in Pediatrics, 21, 345-369. Solomon, J., & George, C. (1999). The development of attachment in separated and divorced families: Effects of overnight visitation, parent and couple variables. Attachment and Human Development, 1, 2 - 33. Spitz, R. (1945). Hospitalism: An inquiry into the genesis of psychiatric conditions in early childhood. The Psychoanalytic Study of the Child, 1, 53-74. Stovall, K., & Dozier, M. (1998). Infants in foster care: An attachment theory perspective. Adoption Quarterly, 2, 55-88. Tyler, R., Howard, J., Espinosa, M., & Doakes, S. (1997). Placement with substance-abusing mothers vs. placement with other relatives: Infant outcomes. Child Abuse & Neglect, 21, 337-349. Wobie, K., Eyler, F. D., Conlan, M., Clarke, L., & Behnke, M. (1997). Women and treatment in residential treatment: Outcomes for mothers and their infants. Journal of Drug Issues, 27(3), 585-606. Zuravin, S., & DePanfilis, J. (1997). Factors affecting foster care placement of children receiving child protective services. Social Work Research, 21(1), 34-42.

Types of orders and authorities: children in care

• Authorities 
• Parental Authority for Placement 
• Voluntary Custody Agreement (VCA) 
• Investigation and Assessment orders 
• Care and Protection Orders 
• 12-Month orders 
• Guardianship of the Minister until 18 years 
• Other Person Custody
• Guardianship Grounds for applying for Youth Court Orders

Authorities

There are two types of Authorities to allow children to be placed into the temporary care of Families SA with the agreement of the parent/guardians that do not require going to Court.
These are

• Parental Authority for Placement
• Voluntary Custody Agreements

Parental Authority for Placement

The Parental Authority for Placement is used in emergency situations when a child or young person, due to a particular family crisis such as illness of the parent, requires a placement in alternative care for a brief period of time.
The custody and guardianship of the child remains with the parent/guardians of the child/young person. Parent/guardians are involved with the social worker in making decisions about the child.
A Parental Authority for Placement can be agreed to for a maximum of six weeks, and can be renewed giving no more than a maximum of twelve weeks in care.

Voluntary Custody Agreement

A Voluntary Custody Agreement is used when:

• There are concerns for the safety of the child which cannot be resolved while the child remains at home, but Families SA anticipates that the goal to create a safe environment for the child to return to will be achieved in a short period of time.
• Parents/guardians are willing to be actively involved in a partnership approach with Families SA.

During a Voluntary Custody Agreement Families SA, the child/young person and the parents/guardians work together to:

• Identify the problems
• Establish common goals
• Take responsibility to achieve these goals
• Improve the family’s circumstances so that everyone is confident that the family situation leading to the Voluntary Custody Agreement is resolved.

During a Voluntary Custody Agreement, Families SA is responsible for the day to day care and decision making of the child, but the parent/guardians remain the legal guardians and still have responsibility for the long-term welfare of the child.
This means that Families SA is responsible for where the child will stay and be looked after, their schooling needs, and their health, but will also work closely with the parents during this period.
Signed consent of both guardians is required. If this is not possible the reasons will be recorded by the Families SA case manager.
If the young person is over 16 years of age, the agreement cannot proceed without the young person’s signed consent.
When the child/young person is under 16 years of age, Families SA will discuss the agreement and the case plan with them in a way that is appropriate for their age level and maturity.
Consent can be withdrawn at any time, in writing. However, if the family issues that led to the Voluntary Custody Agreement are not resolved, Families SA may need to consider applying for formal Youth Court Orders.
The Voluntary Custody Agreement is for a period up to three months. In special circumstances they may be extended up to another three months to a maximum of no more than six months in total.
An important part of a Voluntary Custody Agreement is the “Case Plan”.

Orders

Youth Court Orders are the Legislative Authority that Families SA apply for and use to place a child in care.
The Children’s Protection Act 1993 is the legislation that sets out the types of orders the Youth Court can make for the care of a child/young person.
The Children’s Protection Act states that every child has a right to be safe from harm. It also states that every child has a right to be cared for in a safe and stable family environment, and that when making decisions, the child’s wellbeing and best interests are to be the paramount considerations.
Families SA apply to the Youth Court for an Order so that they can continue to work with the family, and so that they can make decisions and arrangements for the care of the child during any period of further involvement.
See Grounds for applying for Youth Court Orders for more about the reasons Families SA can apply for a Youth Court Order.
Although, Families SA may remove a child from their parent/guardians after assessing that the family environment is not safe or stable, it is the Youth Court Judge that ultimately makes the decision for the removal to be longer term.
There are two main types of Youth Court Orders used by Families SA.
These are

• Investigation and Assessment Orders
• Care and Protection Orders

Investigation and Assessment orders

Initially Families SA will seek an Investigation and Assessment Order to allow Families SA time to complete the inquiry into allegations of abuse and/or neglect, and also review and consider the outcomes with the family’s circumstances as a whole, whilst also ensuring the child’s safety and wellbeing during the investigation process.
Investigation and Assessment Orders can be granted for up to 42 days, and may be extended for a further 42 days.
Investigation and Assessment Orders may or may not include the child being placed under the custody of the Minister while the investigation and assessment occurs.
Investigation and Assessment Orders are most often used when parents are unwilling to work cooperatively with Families SA to ensure the safety and wellbeing of their child while investigation and assessment occurs, or when the concerns raised are so serious that only a court order can ensure their child’s safety during the investigation and assessment process.
If after the Investigation and Assessment period it is assessed that the child still cannot return home, Families SA may apply for a 12-month Care and Protection Order to help the family resolve their issues and where possible try to reunify the child with their parents.
In situations where Families SA believe reunification cannot be achieved within the time frame of a 12-month order, they may consider to apply directly for a Care and Protection Order until the child reaches 18 years.

Care and Protection Orders

Care and Protection Orders can be made for either a period of up to 12 months, or for a period until the child reaches 18 years of age.
There are also certain circumstances where another person can become the child’s guardian instead of the Minister.
To find out more go to the section Other Person Custody and Guardianship

12-Month orders

Custody Or Guardianship Orders

12-Month Care and Protection Orders are most often used to ensure a child’s safety and wellbeing while Families SA continue to help the parents address outstanding child protection concerns, improve their parenting skills, and ultimately have their children returned to them. Families SA refer to this process as reunification.
Families SA often apply for Guardianship of the Minister during this period, but in some circumstances it may be appropriate for the parents to retain the Guardianship and that the Minister, or other,  have Custody of the child.
An example of this is where a parent is incarcerated longer than the legal period for a Voluntary Custody Agreement (6- months) and there are no other concerns for the child.

Supervision Orders

Sometimes the Youth Court may grant Care and Protection orders that direct parents to participate in services or programs to improve their parenting and protectiveness of children, but still allow the parents to retain full parenting rights and responsibilities (Custody and Guardianship). These orders are often called “supervision orders”. In these cases, the child remains at home with the parents, but Families SA has the legal mandate to be involved with the family for a period of time.
If during the 12-month Care and Protection Order, the family are addressing the safety and harm concerns that led to the Order, and the child is in the process of being reunified with their parents, Families SA may apply for an extension of the Order to help complete this process. However, if it becomes clear that the family issues will take a very long time to resolve then Families SA will need to apply for a Care and Protection Order until the child reaches 18 years.

Guardianship of the Minister until 18 years

Care and Protection Orders to 18 years are used when parents are unable or unwilling to make the required changes necessary to secure the child’s safety and wellbeing.
Children cannot wait indefinitely for parents to change, and timely decisions about the child’s future care arrangements need to happen to ensure that children can grow up and reach their full potential.
Care and Protection Orders to 18 years always include Guardianship, and this may be to the Minister, or to another person or persons (up to a maximum of two people).
When children are placed under Care and Protection Orders to 18 years their parents still remain their parents – unlike adoption whereby the child legally becomes the adoptive parents’ child.
Although parents will no longer be the primary decision-makers about their child’s future, parents are encouraged to work in partnership with Families SA, and with the carers, to help their child reach their developmental potential. This includes maintaining relationships with their family of origin, community and culture.

Other Person Custody and Guardianship

Families SA has the ability to apply for other people besides the Minister to be the child’s guardian when Care and Protection Orders are required.
When Families SA applies for Care and Protection Orders to 18 years, Families SA will consider whether it is in the child’s best interests to be under the Minister’s guardianship or another person’s guardianship – this may be a relative, foster carer, or community member. These decisions are made on an individual case-by-case basis, and after thorough assessment and planning. Families SA encourages all parents to be involved in this assessment and planning process.
For more information,

• Other Person Guardianship Program - Fact sheet 1 (PDF, 300KB)
• Other person guardianship - Information for carers - Fact sheet 2 (PDF 88KB)
• Other person guardianship - Information for parents and families - Fact sheet 3 (PDF 80KB)

Grounds for applying for Youth Court Orders

Families SA must have reasons to apply for a Youth Court Order. These reasons are referred to as Grounds.
Families SA has Grounds to apply for Youth Court Orders if a child is deemed to be at significant risk of serious harm to his or her physical, psychological, or emotional wellbeing, against which s/he should have, but does not have, proper protection.
Families SA can also apply for Youth Court Orders on one, or more, of the following Grounds:

• the child has been, or is being, abused or neglected
• a person with whom the child lives has threatened to kill or injure the child and there is reasonable likelihood of the threat being carried out
• a person with whom the child lives has killed, abused or neglected some other child and there is reasonable likelihood of the child in questions being killed, abused or neglected by that person
• the guardians of the child are unable or unwilling to care for and protect the child, or exercise adequate supervision and control over the child
• the guardians are dead, have abandoned the child, or cannot be found
• the child is of compulsory school age but has been persistently absent without satisfactory explanation, or
• the child is under 15 years of age and is of no fixed address.