The 400,000 children in foster care are at extremely high risk for medical, nutritional, developmental, behavioral, and mental health problems. At the time of placement in foster care, most of these children have received incomplete medical care and have had multiple detrimental life experiences. Comprehensive assessments at the time of placement reveal many untreated acute medical problems, and nearly half of the children have a chronic illness. Developmental delays and serious behavioral or emotional disorders are common.
Ideally foster care provides a healing service for these children and families, leading to reunification or adoption. Too often children experience multiple changes in placement within the foster care system, further exacerbating the problems foster children may have in forming a secure relationship with adult caregivers. Children may manifest this difficulty by resisting foster parents’ attempts to develop a close relationship. This detachment from the foster parent may be difficult for the foster parent to endure, which may perpetuate a cycle of placement failures. The trauma or neglect experienced that led to the need for foster care in combination with instability of placements causes enduring long-term difficulties. Foster care alumni report rates of anxiety disorders, depression, substance abuse, and posttraumatic stress disorder that are two to six times higher than in the general population. Furthermore although the protections of the foster care system often end at 18 years of age, these adolescents rarely have the skills and maturity needed to allow them to be successful living independently. Thus the Fostering Connections to Success and Increasing Adoptions Act of 2008 mandates that effective transition to adulthood planning be done with youth in foster care.
The challenges for the foster care system are great. However when children are placed with competent and nurturing foster parents and provided coordinated care from skilled professionals, significant improvements in a child’s health status, development, and academic achievement usually occur.
Failure to meet a child’s physical needs for protection or nutrition results in some of the most severe forms of family dysfunction (see Chapters 21 and 22). There are many other ways in which parental behaviors can interfere with a child having a healthy and safe environment, such as prenatal and postnatal substance abuse. Prenatal use of alcohol can damage the fetus resulting in spectrum disorders known as fetal alcohol spectrum disorders (FASD). At the most severe end of the spectrum, this teratogen causes fetal alcohol syndrome (FAS) characterized by in utero and postnatal growth retardation, microcephaly, intellectual disability, and a characteristic dysmorphic facial appearance. Other manifestations of FASD include birth defects and problems with coordination, attention, hyperactivity, impulsivity, learning, or behavior. Children with these difficulties may be diagnosed with alcohol-related neurodevelopmental disorder, alcohol-related birth defects, or partial FAS.
Other substances also may affect the fetus, but investigation of these effects is complicated by the fact that often more than one substance is used, and nutrition and prenatal care are not optimal. Cigarette smoking during pregnancy is associated with lower birth weight and increased child behavioral problems. Use of cocaine in the perinatal period has been associated with prematurity, intracranial hemorrhages, and abruptio placentae. Exposure to opiates in utero can result in prematurity and a neonatal withdrawal syndrome. Investigations of the effects of cocaine and opiates on cognitive development have produced mixed results.
Parental substance abuse after the child’s birth is associated with increased family conflict, decreased organization, increased isolation, and increased family stress related to marital and work problems. Family violence may be more frequent. Despite the fact that these parents often have difficulty providing discipline and structure, they may expect their children to be competent at a variety of tasks at a younger age than non-substance−abusing parents. This sets the children up for failure and contributes to increased rates of depression, anxiety, and low self-esteem. The parents’ more accepting attitude toward alcohol and drugs seems to increase the chance that their children will use substances during adolescence.