Wednesday, December 21, 2005

An Analysis of Foster Care Policy and its Impact on Occupational Therapy

Identifying Information

Foster care is defined by the United States Government Department of Health and Human Services as "24-hour substitute care for children outside their own homes… [and] includes all children who have or had been in foster care at least 24 hours. The foster care settings include, but are not limited to family foster homes, relative foster homes…, group homes, emergency shelters, residential facilities, childcare institutions, and pre-adoptive homes." (DHHS, 2003a). According to the most current governmental data, 523,000 children were in foster care on September 30, 2003 (DHHS, 2003b). Children are placed in temporary foster homes when their parents are unable to care for them. Foster care is generally designed as a temporary service for children and families who are experiencing a crisis. New York State outlines specific regulations for foster care (18 NYCRR 421).

History of the Policy

Children in foster care have historically been disenfranchised and underprivileged. Under rules of English Poor Law, colonial parents indentured their children into new homes so that the children could learn trade skills. In the 1850s, ‘orphan trains’ transported orphaned children into western states where they were used for farm labor (Johnson, n.d.). By the early 1900s, some private placing agencies were making board payments to foster parents and ultimately the federal government began regulating foster care under a program created by Teddy Roosevelt. (Hacsi, 1995). The Social Security Act of 1935 included aid for various child welfare programs that led to expansion of foster care. In 1980 the Adoption Assistance and Child Welfare Act provided federal funding to states that promoted adoption of children with disabilities and supported creation of state policies regarding family preservation and reunification. In 1997 the Adoption and Safe Families Act changed regulations in order to improve the safety of children, to promote adoption and other permanent homes for children who need them, and to support families. There are ongoing policy initiatives coming from the 1997 act that are designed to move children from foster care into adoption.

Goals of the Policy

Foster care policy is designed to be supportive of more general child welfare programs. The United States Department of Health and Human Services, through the Administration for Children and Families, provides support and assistance to states so that they are able to implement foster care programs. The stated purpose of these programs is to “promote the well-being of children by ensuring safety, achieving permanency, and strengthening families to successfully care for their children (DHHS, 2005a).”

Children and families are supposed to be the primary beneficiaries of this policy. The American Academy of Pediatrics identifies that most children in foster care experienced abuse, prolonged neglect, and a lack of a stable home environment (AAP, 2000). This multitude of risk factors places children at higher risk for developmental pathology (Zeanah, 2000, p. 109). Accordingly, these children are at greater risk for problems relating to their occupational performance and this has a subsequent effect on the entire family system. Successful foster care placement is supposed to ameliorate these negative factors and promote child wellness and improved family functioning. Reunification and healthy family functioning are the expected outcomes of successful foster care placement. If this is not possible, placement of children in healthy and safe environments is also an acceptable alternative objective. Successful foster care placement provides emergency relief for children and families so that they have an opportunity to work toward improved functioning.


Each state sets its own criteria and licensing requirements for foster parents as well as support services and other relevant foster care policies. The New York State foster care program is administered through the Office of Children and Family Services (OCFS). The state coordinates this program through each county.

Criticism regarding implementation of foster care programs is widely reported. Although abuse and neglect by foster parents is statistically low, there are still an estimated 0.05 to 1.62 percent of the children in foster care who are abused and neglected by foster parents (DHHS, 2003c). This statistic is reportedly decreased from prior years.

Despite large federal and state programs, children in the foster care system remain at high risk for many different problems. Halfon, Mendonca, & Berkowitz (1995) report that over 80% of the foster care children in their clinical cohort had developmental, emotional, or behavioral problems. This population of children requires coordinated and integrated service delivery.

There is a tremendous amount of complexity in foster care systems. A multitude of social service agencies has to interact to provide services for children. These include court systems, state and local child welfare systems, private service providers, public agencies, and Medicaid (Bass, Shields, & Behrman, 2004). All of these programs intersect and have a summative impact on children in foster care.

To improve New York State’s approach to foster care and child welfare programs in general, an Integrated County Planning (ICP) Project was implemented by the OCFS and counties between 1998 and 2003 (Greene, McCormick, & Lee, 2005). The purpose of this project was to improve county level collaborative planning and to implement broad child and family service policies consistent with the stated policies of the OCFS. This type of demonstration project is an example of a broad policy initiative that represents beginning action toward improving overall service provision and coordination.

Changes over time

Reporting data to the DHHS is listed according to recent time frames, with the most recent comparative data presented covering the periods between 1998 and 2001 (DHHS, 2003d). During this period, entries into foster care stayed relatively stable, while exits increased slightly and the number of children in care at any one point in time dropped slightly. Placement type at any given point in time remained relatively unchanged. Placement in relative foster homes showed the largest change, dropping 5 percentage points. Regarding permanency goals, the most dramatic change occurred in the proportion of children in the "No Goal Established" category, which posted a decrease of 12 percentage points. Exits to reunification decreased by 5 percentage points. The time children spent in foster care remained relatively unchanged. The age at entry and exit stayed relatively stable between, while the median age of all children in care at a given point in time increased by 1.1 years. The percentage of Black/Non-Hispanic children in care at any given time dropped 6 percentage points; rates for all other race/ethnicity categories increased slightly. The racial composition of children entering and exiting foster care stayed relatively stable. Gender demographics were also unchanged in this time period.

In summary of the above, there have not been large changes in the recent past regarding foster home placements when analyzing aggregate data across the country.

New York State reports significantly greater success in their foster care program. New York State has decreased its foster care population from a high of 53,902 children in 1995 to 29,680 in 2004 (OCFS, n.d.). However, a close analysis of the statistics on the OCFS website indicates that although admissions into foster care and the total number of children in care is trending downward, the number of children discharged from the system is decreasing steadily each year.


Recent data shows that over 50% of all children remain within the foster care system for periods of time that exceed eighteen months, and 16% of all children in foster care remain within the system longer than five years (DHSS, 2003b). On average, approximately 85% of children who are in foster care for less than one year experience two or fewer placements, but placement instability increases with each year a child spends in the system (DHHS, 2003c). Ultimately, 57% of the children in foster care are reunified with their birth parents, although in recent years, reunification rates have declined (DHHS, 2003b). Terling (1999) states that reentry into foster care due to additional maltreatment occurs too frequently, and that 37% of the children reunited with their families reenter the system within 3 1/2 years. These statistics indicate that although large numbers of children are successfully cared for in the foster care system, there are still many problems with the system that need to be addressed by new and improved policies.

There have been significant changes in federal budgetary allocation to state foster care programs over time. The federal government currently spends approximately $5 billion per year to reimburse States for a portion of their annual foster care expenditures (DHHS, 2005b). Since 1961, the federal government has shared the cost of foster care services with states. Prior to this time foster care was entirely a state responsibility. Congress created federal foster care funding in response to states that dropped children and families from welfare assistance because of homes that were ‘unsafe.’ Federal funding insured that families would still be able to receive assistance even if their homes were determined to be ‘unsafe.’

Until 1980, federal foster care funding was part of the federal welfare program, Aid to Families with Dependent Children (AFDC). Since 1980 foster care funds have been authorized separately under title IV-E of the Social Security Act. Title IV-E did not significantly change until the passage of the Adoption and Safe Families Act in 1997. Federal foster care program expenditures grew an average of 17 percent per year in the 16 years between the program's establishment and the passage of the Adoption and Safe Families Act (DHHS, 2005b). Now, growth in expenditures is increasing dramatically as compared to the number of children in foster care.

The Adoption and Safe Families Act improved the standards for foster-care practice. Child and Family Service Reviews were mandated by Congress to assess how well states are meeting the standards and these have been reported for several years (DHHS, 2003c). Researchers and policy analysts need to examine this data and begin to determine which states have effective policies that are resulting in improved performance. Conversely, analysis of policy failures can be helpful and instructive in determining foster care ‘best practices.’ The issues surrounding child welfare programs are complex and given the large federal budgetary allocation it would not seem difficult to convince people that efficiency and effectiveness are needed to implement our broad policy objectives.

Impact on Occupational Therapy

Although researchers continue to explore the relationships between foster care and developmental outcomes, not many studies have directly measured aspects of occupational performance that are commonly considered by occupational therapists, such as acquisition of self care, academic, and play skills. Additionally, drawing direct conclusions is difficult because of the multitude of risk factors that children in foster care are typically exposed to. The impact of foster care placements on occupational performance must be inferred from the known impact on subcomponents of performance.

It is well accepted that stress responses associated with abuse, maltreatment, and neglect have a negative impact on children’s behavior (AAP, 2000). Because of the wide-ranging impact of stress, the following areas should be assessed for all children entering foster care: gross and fine motor skills, cognition, speech and language function, self help abilities, emotional well being, coping skills, relationships to persons, adequacy of caregivers parenting skills, and behaviors (AAP, 2000). All of these areas are important aspects of performance that contribute to children’s occupations.

Children in foster care are often provided occupational therapy services through early intervention, preschool, or school-based systems. However, there is little coordination between the legal system, the social services system, and the related services delivery systems. The service delivery systems that provide care for children are complex and overlapping; coordination is not always optimal, and ‘best practice’ models that are described in the literature are very difficult to implement. The result of this complexity is that children who are in foster care do not always receive an optimal delivery of supportive services.

Occupational therapists working in pediatrics need to increase their basic knowledge of foster care and its impact on children and families. There is a strong need for case studies published in the literature that will provide beginning information for the development of practice models to guide occupation-based interventions.

References: (Links take you off the page; use the BACK button to return).

Adoption and Safe Families Act (1997). Public Law 105-89.

Adoption Assistance and Child Welfare Act (1980). Public Law 96-272. 42 U.S.C. §§ 670

American Academy of Pediatrics (2000). Developmental issues for young children in foster care. Pediatrics, 106, 1145-1150.

Bass, S., Shields, M.K., & Behrman, R.E. (2004). Children, families, and foster care: Analysis and recommendations. The future of children. Retrieved December 10, 2005 from

Greene, R., McCormick, L.L., & Lee, E. (2005). Integrating the human service system: Final evaluation of the NYS Integrated County Planning Initiative, Albany, NY: Rockefeller College of Public Affairs and Policy.

Hacsi, T. (1995). From indenture to family foster care: A brief history of child placing. Child Welfare, 74, 162-80

Halfon, N.G., Mendonca. A., & Berkowitz, G. (1995), Health status of children in foster care: The experience of the Center for the Vulnerable Child. Archives of Pediatrics and Adolescent Medicine, 149, 386-392.

Johnson, M.E. (n.d.) Orphan train movement: A history of the orphan trains era in American History. Retrieved December 10, 2005 from

National Foster Parent Association (n.d.) History of Foster Care in the United States. Retrieved December 10, 2005 from

New York State Office of Children and Family Services (OCFS), (n.d.). A Message from Commissioner John A. Johnson. Retrieved December 10, 2005 from

New York State Office of Children and Family Services (2004). 2003 Monitoring and Analysis Profiles with selected trend data 1999-2003: Child protective services, preventive services, foster care, and adoption in NY State. Retrieved December 10, 2005 from

New York State Rules and Regulations, Title 18 NYCRR Part 421. Standards of practice for adoption services.Social Security Act of 1935. Retrieved December 10, 2005 from

Terling, T. (1999). The efficacy of family reunification practices: Reentry rates and correlates of reentry for abused and neglected children reunited with their families. Child Abuse & Neglect. 23, 1359-1370.

U.S. Department of Health and Human Services, Public Welfare Regulations, 45 CFR1355 57 (October 1, 2003a).

U.S. Department of Health and Human Services. (2003b). The AFCARS report: Preliminary FY 2003 Estimates as of April 2005. Retrieved December 10, 2005, from

U.S. Department of Health and Human Services. (2003c). Child welfare outcomes 2002: Annual report. Safety, permanency, well-being. Retrieved December 10, 2005 from

U.S. Department of Health and Human Services. (2003d). Foster care national statistics. Retrieved December 10, 2005 from

U.S. Department of Health and Human Services, Administration for Children and Families. (2005a). How Does the Child Welfare System Work? Retrieved December 10, 2005 from

U.S. Department of Health and Human Services, Administration for Children and Families. (2005b). Federal foster care financing: How and why the current funding structure fails to meet the needs of the child welfare field. Retrieved December 10, 2005 from

Zeanah, C. H. (2000). Handbook of infant mental health (2nd ed). NY: Guilford.

1 comment:

Blue Cross of California said...

Great blog I hope we can work to build a better health care system. Health insurance is a major aspect to many.