Foster care for Young Children: Outcomes and Costs
(Originally published February 2018)
One of the distinguishing features of U.S. foster care systems is the percentage of children 0-5 in foster care - about 50% of children in out-of-home care in most states. Nearly a fifth of children who enter foster care are infants, 0-1; more than 49,000 infants entered foster care in FY 2016, according to AFCARS statistics. Infant placement rates per 1000 children are more than double the rates for any other age group, even toddlers. Most young children are placed out-of-home due to combinations of neglect, substance abuse and other co-occurring disorders. As children become older histories of multiple types of child maltreatment become more common among foster children. U.S. foster care systems have been shaped by strong associations between and among high child poverty rates, weak family support systems, and the breakdown of low income families due to chronically relapsing conditions such as substance abuse and mood disorders. The difficulty in maintaining a consistent structure of care for young children is one of the early indicators of family breakdown, with the result that CPS reports of neglect far outnumber reports of physical abuse or sexual abuse.
Nationally, approximately 50% of children are reunified with birth parents, sometimes within a few days or weeks, while about 20% of foster children are adopted. However, reunification rates are much lower for infants in foster care. In a Washington State study I co-authored almost a decade ago, more than half (56%) of children placed in foster care as infants were eventually adopted, often after several years in care, while about a third of infants (32%) were reunified with a birth parent. In U.S. child welfare systems, foster care for infants, toddlers and other preschool children is often a pathway to adoption, much more so than for school age children. This is one of several important differences between foster care for young children compared to school age children, especially children 9-17.
Does foster care reduce child deaths among young children?
In 2011, Emily Putnam-Hornstein published a ground breaking study of child deaths due to injury, both intentional and unintentional, for 4.3 million children born in California from 1999-2006. This study found that children named in a CPS report (including screened out reports) were almost 6 times more likely to die of an intentional injury and twice as likely to die of an unintentional injury by their fifth birthday than children who were not reported to CPS. After controlling for a variety of factors, including socioeconomic status, this study found that a CPS report during a child's first few years of life was the strongest single risk factor for injury related death. A subsequent study using a large birth cohort found a highly elevated rate of SIDS deaths among young children reported to CPS. There is no information in this study regarding the effects of foster care placement during infancy on injury death rates - a curious omission given the availability of an administrative data base that could provide an answer to this question. In a subsequent study, Putnam-Hornstein, et al, found that about 5% of infants born in California were reported to CPS before age 1; almost one fifth of infants (18%) named in CPS reports were placed in out-of-home care after the first CPS report with the remaining 80% of infants and their parents receiving few, if any, services.
An exemplary study that examined the relationship between CPS involvement and foster care on child mortality (from all causes) was completed in Washington State during the 1990's. Mortality of CPS Clients in Washington State From Birth to Age Four is an unpublished study conducted by Laurie Cawthon and David Hopps, two researchers employed at the time by Research and Data Analysis, a part of DSHS, the state's umbrella human services agency. These researchers examined CPS referral data for 274,984 children born in Washington State between July 1, 1991 and December 31,1994 through 1995. They also tracked mortality rates for this large birth cohort through December 31,1995. Most of the children in this sample were younger than 4 at the time the study was completed.
A major finding of this study was that “After controlling for a number of other risk factors,
Medicaid children with CPS referrals (accepted and unaccepted) had a two-fold increased risk of death in early childhood (after the first month of life). No increased risk of death was found for children with out-of-home placements after controlling for other factors.” Almost 92% of all child deaths in this sample occurred during the first year of life, so this study's findings regarding the protective effects of foster care on child death rates apply mostly to placements of infants:
Post neonatal Mortality rate
(months 2-12) (per 1,000)
All Births 2.9
Medicaid (no CPS) 3.9
Medicaid (CPS) 7.8
Non Medicaid (CPS) 8.6
Non Medicaid (no CPS) 1.9
Children in Foster Care 3.3
According to the authors, “SIDS was the leading cause of post neonatal death in all study groups.” Congenital anomalies “was the second leading cause of death for all groups except the Accepted CPS Referral-Medicaid group. In that study group, Accidents and Adverse Effects caused more post neonatal deaths.” More than half of young children reported to CPS (accepted and unaccepted referrals) had diagnosed medical conditions, twice the rate for children not reported to CPS. The authors comment that “higher mortality rates among children experiencing CPS involvement, may, in part, have been due to a higher frequency of physical ailments.”
This study found that more than 80% of CPS involved children were reported after the first month of an infant's life. Eleven children (out of 3697) reported to CPS but not placed out of the home during the first 28 days of life died; no children placed in foster care during their first month of life died. The authors comment that only 1 in 80 (1.2%) of children who died during their first month of life had been reported to CPS.
Foster care placement was a major protective factor in reducing child deaths from all causes in this study, but perhaps the study's most important finding was the seriously compromised health of young children reported to CPS. Child protection programs need both the mindset and the resources to help birth parents cope with the serious medical problems of infants and toddlers rather than maintaining a concentrated focus on safety threats associated with abuse and neglect. A plausible hypothesis is that better quality of care for children with serious medical conditions was the main factor in reduced mortality rates for young children in foster care compared to CPS involved children who remained in the home of birth parents.
No one study can prove that foster care protects the lives of young children. Cawthon and Hopps completed this study more than twenty years ago using a birth cohort of children from the early 1990's. Nevertheless, this is a compelling study with important findings that deserves to be widely replicated. Top DSHS managers in Washington State should be asked to explain why this study was never published. If DSHS managers in the late 1990's refused to allow the publication of this study because they did not like it's findings, the persons responsible should be held accountable, at least in the court of public opinion.
Developmental outcomes for infants and toddlers in foster care
Child welfare practitioners and child advocates may assume (as I did until a few years ago) that foster care would confer developmental advantages on young children removed from parents challenged by substance abuse, often accompanied by mood disorders and sometimes domestic violence as well, along with poverty. Several recent studies have cast serious doubt on this assumption. Some of these studies have utilized samples from the National Study of Child and Adolescent Well Being (NSCAW), one of the best funded, rigorous and most representative studies of child welfare ever conducted in the U.S.. Using a variety of standard developmental measures in a sample of 353 children younger than 13 months of age at baseline from NSCAW I, Richard Barth and Christopher Lloyd found that “Returning to the home of the biological parent and adoption were associated with the most similar, and generally positive, outcomes. Children in foster care had the poorest development on many measures even though children in the in-home condition had less responsive parents and much greater poverty.” However, the authors acknowledge that they lacked credible data regarding placement data for the entire 5-6 years of the study, which suggests the possibility that children's developmental outcomes were influenced by different experiences in out-of-home care rather than by type of care.
Bada, et al, conducted one of the best studies of infants exposed in utero to cocaine or opiates in four cities: Detroit, Miami, Memphis and Providence, R.I.. This study followed 1388 infants for 3 years in the early 1990's. Some of these babies remained with the birth mother following delivery, some were placed in non-kin foster care and some were raised by relatives. Babies in kinship care had the best developmental outcomes while children in foster care and children who remained with their mothers had similar less positive developmental outcomes. Possibly the most important finding of this study was that every placement move caused developmental harm to these young children. Children in kinship care had more stable placements than children in non-kin care. Barth and Lloyd assert that the findings of their study “like Bada et al suggest that placement stability and parental commitment are major forces in development … apparently at least as much of a force than the type of placement, per se.” It appears that young foster children who are stabilized in care quickly and then moved in a timely way to reunification or adoption have the best developmental outcomes. In Barth and Lloyd's NSCAW sample, children who were adopted from foster care had more positive development at baseline, but it's unclear whether reunified children and children who remained in foster care differed in the behavioral challenges they presented to caregivers, or in their physical health.
Another group of scholars who have published research regarding the effects of foster care on early child development (Stahmer et al, 2009), maintain that “foster care does not have a negative effect on child functioning but does not facilitate development either.” However, these scholars also found that in their NSCAW sample “children with lower BL (i.e., baseline) developmental/cognitive scores.. placed in out-of-home care were found to experience relatively less positive change than children with comparable BL scores who remained at home with no service.” As with older children, the benefits of foster care for young children are greatest among children with developmental advantages at entry into care while children with developmental challenges of various sorts benefit the least.
Costs of foster care for young children
Every child welfare system has a permanency planning failure rate, a percentage of children who lose their birth parents but do not find another legally permanent family, or a stable kinship placement regardless of legal framework. Permanent planning failure rates increase with age at entry into care and are much higher for school age children and youth than for preschool children. Nevertheless, in FY 2014, 15% of adolescents in foster care entered care in their early years (0-5). It is likely that many of these teenagers had failed permanent plans, i.e., reunification or adoption, but it's also true that some kinship placements disrupt after several years due to the failing health of older relatives or because relatives are unable to cope with children's behavior problems.
Foster care during infancy interrupts the development of children's attachment to birth parents and birth parents' emotional connection to infants. Judges and commissioners, child advocates and caseworkers often assume that intensive visitation schedules can compensate for the disruption in a parent-infant relationship due to foster care, but I have yet to read convincing research on this subject. The common sense view that frequent (several times per week) visitation is necessary to strengthen the emotional connections between babies, toddlers and their parents may be correct, but the effects of early foster care on the potential for secure attachment, post reunification, remains uncertain.
There are a few young children who die from abuse or neglect in foster care. During the past few years, there have been stories from around the country of young foster children who died after beatings, drug overdoses, medical neglect, i.e., the same types of causes associated with child maltreatment deaths in birth families. The exact number of these deaths is uncertain, but they occur every year in multiple states. Foster care does not guarantee child safety, even for infants and toddlers.
Finally, child welfare systems that place more than130,000 children (0-5), including almost 50,000 infants per year, through legal actions that create the potential for termination of parental rights, are exacting a heavy emotional toll on the birth parents of these children. The emotional damage experienced by birth parents as a result of involuntary child removals is deeply troubling to many child welfare practitioners, advocates and professionals who work with these parents. Any humane society would attempt to find safe alternatives to foster care, and several promising practices have been utilized to varying degrees in many states. These alternatives include Pregnant and Parenting Women residential drug treatment programs, intensive home visitation programs such as PCAP in Washington State, day treatment programs such as Oregon's Relief Nurseries, transitional housing programs and baby courts. Foster parents can be utilized (and compensated) as resource families for birth parents following reunification.
It has been difficult to take these programs to scale due (in part) to cost, but also because of social attitudes that justify the harsh treatment of abusive and neglectful parents, substance abusers and desperately poor families. The one lesson that every child welfare practitioner and child advocate needs to learn is that compassion for vulnerable children and compassion for their parents are not opposed states of heart and mind. The most effective professionals and advocates who work in and around child welfare demonstrate both perspectives on a daily basis.
Bada, H., Langer, J., Twomey, J., Bursi, C., Lagasse, L., Bauer, C., Shankaran, S., Lester, B., Higgins, R. & Maza, P., “Importance of Stability of Early Living Arrangements on Behavior Outcomes of Children With and Without Prenatal Drug Exposure,” Journal of Developmental and Behavioral Pediatrics, 29, 3, 173-182.
Barth, R. & Lloyd, C., “Five Year Developmental Outcomes for Young Children Remaining in Foster Care, Returned Home, or Adopted,” Chapter 2 in How Does Foster Care Work?: International Evidence of Outcomes, ed. by Fernandez, E. and Barth, R., Jessica Kingsley Publishers, 2010.
Brennan, K., Wilson, D., George, T. & McLaughlin, O., Washington State Court Appointed Special Advocate Program Evaluation Report, University of Washington School of Social Work & Washington State Center for Court Research, 2010.
Cawthon, L. & Hopps, D., Mortality of CPS Clients in Washington State, Research and Data Analysis, Department of Social and Health Services, 1997.
Putnam- Hornstein, E., “Report of Maltreatment As a Risk Factor for Injury Death: A Prospective Birth Cohort Study,”, Child Maltreatment, 16 (3), 163-74, 2011.
Putnam- Hornstein, E., Simon. J., Eastman, A. &, Macgruder, J., “Risk of re-reporting among infants who remain at home following alleged maltreatment,” Child Maltreatment, vol. 20 (2), 2015.
Stahmer, A., Hurlburt, M., McCue Horowitz, S., Landsverk, J. , Zhang, J. & Leslie, L., “ Associations between intensity of child welfare involvement and child development among young children in child welfare,” Child Abuse and Neglect, vol. 33, 9, September 2009.
Sounding Boards, 2009-2018, are available at www.deewilsonconsulting.com/writings