Special Considerations for Children in Foster Care

Children in foster care commonly face adversity far exceeding that of typical childhood. All children experience tolerable, temporary stressors as a normal part of learning and growing, such as a first day in a new school or performing on stage in front of an audience. These experiences are healthy and help build resilience. For children in foster care, their placement is often triggered by circumstances of ongoing stress and adversity, such as neglect, abuse, domestic violence, or parental mental health or substance abuse challenges. Chronic stress in the absence of a consistent, caring adult can elicit a toxic stress response in the brain and body, drastically impacting childhood growth and development and altering neural connections, stress hormone responses, and even gene expression. The severe stress experienced by children who are placed in foster care can lead to both physical and behavioral challenges that impact that child throughout their lifespan.

Safe, stable, and nurturing relationships are vitally important for children to grow and thrive. These relationships, most often with a parent or caregiver, support children in facing life’s normal stressors and challenges, help them build resilience, and—when more serious and ongoing adversities occur—buffer them from the effects of the toxic stress response. However, children in foster care often lack these stable and consistent adult relationships.

Because foster parents, reunified biological parents, and other caregivers will often look to their child’s medical provider for answers to any physical, behavioral, and mental health challenges their child experiences as a result of their cumulative life experiences, it is critically important for pediatricians to understand the unique impact that relational instability and exposure to unbuffered chronic stress has on children in foster care. Physical or behavioral problems a child exhibits may be the result of their previous trauma history, which can be compounded by parental or caregiver instability. Though challenging, counseling parents and caregivers on the neuroscience behind a child’s adaptive behaviors is key to helping the child heal. Everyone involved in the life of a child in foster care must approach the child with empathy, asking “What happened to you?” instead of “What’s wrong with you?”

Pediatricians who provide care for children in foster care face several unique challenges. Prior to being placed in foster care, a child’s health care may have been fragmented and inconsistent. Additionally, the child may lack a health historian if the foster parent is not made aware of previous health conditions. Children in foster care may also have greater physical, dental, behavioral, and mental health needs than children who are not involved in the child welfare system. For these reasons, it is recommended that children in foster care visit their pediatrician more often to monitor ongoing issues, detect new problems quickly, and provide support to caregivers for any challenges the child may be facing. In addition, it is important to realize that most children in foster care will eventually reunify with their biological parents. When appropriate, engaging parents in the child’s health care when the child is not living with them will better position parents to support the child when returned to their care.

Key concepts for pediatricians:
– Children in foster care may have experienced chronic, extreme stress.
– Ongoing, severe stress can elicit a toxic stress response in the body that may impact brain development, stress hormone response, and other important biological processes during a critical time of a child’s growth and development.
– Children in foster care often have not had the benefit of stable and supportive adult relationships, which buffer the effects of the toxic stress response and help children grow and thrive.
– Behavioral challenges are often the result of a child’s adapting to chronic adversity, a symptom of their past experiences.
– These behaviors are challenging for caregivers.
– Children are testing whether their caregiver will stick with them, which may not have occurred in past relationships.
– Children in foster care should be viewed through a trauma-informed lens. Examine challenging behaviors as if you were asking the child, “What happened to you?” instead of “What’s wrong with you?”
– Children in foster care have often had fragmented or absent health care prior to placement into foster care.
– Lack of a medical historian, incomplete health history, difficulty obtaining consent for certain treatments or medications can be additional challenges.
– Children in foster care often have greater physical, dental, behavioral, and mental health problems than children who are not in foster care.
– All children in foster care should establish a medical home and receive more frequent pediatric care to address their needs, monitor for changes, and provide support and guidance to caregivers.
– Most children in foster care are eventually reunited with their biological parents or guardians. Engaging those adults in the child’s care whenever appropriate will benefit both the adults and the child moving forward. Supporting the caregivers post-reunification can also help ensure a successful transition and improved stability for the child.