foster care

Children in Foster Care: 10 Things Every Pediatrician Should Know

May is National Foster Care Month and a good time to review what pediatricians should know about children in foster care. The following is a summary of a handout based on a presentation titled “Health Needs of Children in Foster Care” given by Moira Szilagyi, MD, PhD, as part of the Pediatrics for the 21st Century Symposium Series at the American Academy of Pediatrics (AAP) 2009 National Conference & Exhibition.1

10 Removal Is Traumatic

Children who are removed from their home are separated not only from parents but also from their community, neighborhood, school, child care center, and sometimes their siblings. This separation from all that is familiar to them is emotionally traumatizing.

The Things They Carry

Children often enter care with few personal belongings—as much as they can carry in a plastic garbage bag—but with an excess amount of complex childhood trauma. These experiences have shaped who they are up to that point. Unfortunately, they often do not carry their health records, medications, and medical equipment.

The Impact of Childhood Trauma

Children learn what they live. It is crucial that pediatricians understand the impact of childhood trauma on the developing brain and its translation into largely predictable emotions and behaviors in maltreated children (eg, insecure attachment, impulsivity, hyperactivity, poor attention, and dissociation). Pediatric practitioners must be able to reframe behaviors for foster parents and other caregivers in ways that might be helpful to them in parenting the child.

The Need for Special Health Care

Because of the very high prevalence of medical conditions among children in foster care, the AAP has defined them as children with special health care needs.
Children in foster care have many of the same health problems as other children but have more of them more often. Here are a few
scenarios that may explain this high prevalence:

Health condition is the direct result of trauma.

Medical neglect.

Parents’ inability to care for the child’s health problems.

Emotional stress may precipitate or exacerbate underlying conditions, such as asthma.

In general, the area of greatest need is mental and developmental health, which stems from the child’s history of trauma and deprivation. Helping children and families find appropriate care and resources for these problems is critical. Children with significant mental health and developmental problems are less likely to find permanency through reunification or adoption. Those who remain in foster care longer and experience more placement changes are more likely to have poor emotional and developmental health.

The many transitions that occur in foster care can have a negative impact on a child’s well-being. Changes, such as having to switch schools, a parent’s incarceration, and inconsistent visits from parents, can make a child feel transient or “disposable.” When a new child enters the foster home (or a child or sibling leaves), children may wonder when they will leave. Being freed for adoption, the severing of all family ties, is another significant transition for the child in foster care.

Barriers to Improving Health Outcomes

The foster care system by design, with its layers of authority and responsibility among multiple parties (caseworkers, courts, foster caregivers, and parents), creates major barriers. The coordination of health care is a significant challenge, from obtaining consents, health insurance, and referrals to maintaining confidentiality and navigating the health system and child welfare system on behalf of the child.

Shared Goals

Pediatric practitioners and foster care programs share the same goals: to ensure the health, well-being, and safety of the children in their care. They are also responsible for providing education and services to both the birth parents so that they can reunite safely with their children and the foster/kinship parents so that the health of the child is optimized.

Foster care is intended to be a temporary intervention that will lead to permanency through reunification or adoption. When reunification or adoption is not possible, pediatric practitioners and foster care programs must prepare the youth for successful independent living.

The Foster Parent

Foster parents are the major therapeutic intervention and the heart and soul of the foster system. While motivated by a desire to heal children and prevent further trauma, foster parents are often undertrained and underprepared for the challenges they face. Pediatric practitioners are in a good position to help foster parents because they can tell the parents about their child’s health, assist in accessing needed services, reframe behavioral concerns, and provide advice on positive parenting strategies and helping children (and parents) manage transitions.


The visit between birth parent and child is intended to provide a safe place for parents to maintain and heal their relationship with their children. It is the best predictor of reunification and can be difficult for both parents and children. Both may relive separation or past trauma or rejection. Parents may make promises they cannot keep or visit unpredictably. Ideally, birth and foster parents work together on the child’s behalf; however, if one somehow undermines or sabotages the other, challenges may arise.

Pediatricians can provide guidance to ensure visitation goes well, by encouraging foster parents to prepare children for visits, or to send along a transitional object or a drawing for their parents. Foster parents should also be present when the child returns from the visit to welcome the child home and provide a safe and comfortable re-entry time.

The Medical Home

A successful partnership between the health provider and the parents/foster parents requires comprehensive holistic care that is accessible and continuous throughout the child’s time in foster care. Care should be well-coordinated, with good communication across health and child welfare. Compassionate and culturally competent care for the foster child means that the staff of the pediatric practice is trauma-informed and understands the impact of foster care, uncertainty, separation, and loss. The medical home should be centered on the child who is living in the context of multiple families.

The Power of You

Don’t underestimate your own role in the lives of children in foster care. For proof, read City of One: A Memoir by Dr Francine Cournos, who grew up in foster care with her sister. In the following quote, she describes her experience with her own pediatrician, “He listened carefully and respectfully to everything I told him. He even seemed to believe me when I said I’d become a doctor someday. I was convinced he took me more seriously than I took myself.” 



Child Welfare League of America

Children’s Defense Fund

Foster Care Alumni of America

Healthy Foster Care America Web site