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Foster Care Placement Improves Children's Functioning
Sarah McCue Horwitz, PhD;
Kathleen M. B. Balestracci, PhD;
Mark D. Simms, MD, MPH
Arch Pediatr Adolesc Med. 2001;155:1255-1260.
ABSTRACT
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Objective To examine changes in reported functioning over a 12-month follow-up
period and predictors of those changes for a cohort of young children enrolled
in foster care.
Design Data came from a longitudinal follow-up of a cohort of young children
entering foster care in one Connecticut region. These data were originally
assembled to evaluate the effectiveness of a specialized set of services designed
to provide a baseline multidisciplinary assessment and ongoing monitoring
for young children entering foster care.
Setting and Participants From February 1, 1992, through July 31, 1993, all young children (N
= 120) entering foster care in one Connecticut region were enrolled in this
study. Children were assessed at entry into care and at 6 and 12 months after
entry. Participation rates exceeded 90% at each follow-up period.
Main Outcome Measures The principal outcome of interest for these analyses is 12-month functioning
as measured by the Vineland Adaptive Behavior Scale (VABS) scores completed
by their foster mothers.
Results At entry into foster care, children ranged in age from 11 to 76 months,
were evenly divided by sex, and had a mean VABS score of 79.5 signifying functioning
below the average range. At 6 months children gained an average of 7.87 points
on their VABS score. By 12 months children showed an average change of 9.65
points, for a mean VABS score of 94.5, well within the nationally normed average
range. The multivariate linear model predicting the 12-month VABS score showed
that, controlling for the baseline VABS score, when children who were abused,
older at placement, female, of African American ethnicity, spent more time
in foster care, and had fewer recommended services while in care, they were
more likely to show improvement on the foster mother–reported VABS evaluation.
Conclusions These results demonstrate that children's reported functioning improves
over the course of placement in foster care and that sociodemographic characteristics,
reason for placement, length of time in foster care, and fewer recommended
services at entry into foster care identified children who were more likely
to improve. These results argue for a careful examination of the foster care
environment to better understand which aspects of the environment contribute
to improved foster mother reported functioning. Such understanding will be
critical for the care and development of maltreated children.
INTRODUCTION
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, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 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 problems11, 17, 18
have been diagnosed in up to 84% of foster children, and 31% to 67% have educational
problems,4, 5, 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, 11, 12, 23, 24, 25, 26, 27, 28, 29, 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, 34, 35, 36, 37, 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, 34, 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.
PARTICIPANTS AND METHODS
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.
MAIN OUTCOME MEASURES
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
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Table 1. Information Collected for All Contacts With the Foster Care
Clinic (FCC) Intervention Children and All Children Placed in Foster Care
in the Comparison Location, Danbury-Torrington, Conn
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Early Screening Profiles
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
VABS Scores
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.
DATA ANALYSIS
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.
RESULTS
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).
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Table 2. Baseline Sociodemographic, Social Services, Developmental,
Physical Health, and Psychological Characteristics of 120 Study Children
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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.
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Table 3. Baseline Sociodemographic Characteristics of 120 Foster Families
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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.
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Table 4. VABS Scores Over Time*
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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.
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Table 5. Multivariate Linear Model Predicting 12-Month After Entry
Into Foster Care VABS* Score
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COMMENT
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.
AUTHOR INFORMATION
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.
What This Study Adds
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.
From the Department of Epidemiology and Public Health (Drs Horwitz
and Balestracci), and The Child Study Center (Dr Horwitz), Yale University
School of Medicine; and the Institution for Social and Policy Studies, Yale
University (Dr Horwitz), New Haven, Conn; and the Department of Pediatrics,
Medical College of Wisconsin, Milwaukee (Dr Simms).
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{at}yale.edu).
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