Foster Care: Challenges and Opportunities to Reducing Health Disparities


Introduction to Thinking about Foster Care: Challenges and Opportunities to Reducing Health Disparities

Christopher Greeley, MD MS FAAP
Robert Sanborn, EdD

A child is placed in foster care when that child is no longer able to safely live at home. A court grants that the state temporarily become the legal guardian for a child, and Child Protective Services is subsequently granted temporary legal possession to place the child in foster care. There are multiple types of foster care settings, including family homes, group homes, and residential group care facilities. According to the Child Welfare Information Gateway, over 425,000 children are in foster care on any given day.1 The most recent Report to Congress of Child Welfare Outcomes was in 2014, when approximately 415,000 children were in foster care nationwide.2 It is widely acknowledged that children in foster care face higher rates of medical and mental health care needs than the general population. Understanding the unique medical needs of foster children will allow providers to screen and provide care for the major health needs in this at-risk population. Numerous studies have demonstrated higher rates of a variety of disorders, including attention deficit hyperactivity disorder (ADHD), depression, anxiety, oppositional defiant disorder (ODD), conduct disorder, post-traumatic stress disorder (PTSD), reactive attachment disorder, and behavioral problems among children in foster care, as compared with the general population. Children in foster care transitioning to adulthood are up to four times more likely to have mental health disorders compared to non-foster children. 3,4 When compared to children not in foster care from similar socioeconomic situations, children in foster care were three to four times more likely to be diagnosed with a range of mental health disorders. 5

There are a number of opportunities for systems improvements that would benefit children in foster care:

Centralized information : For children entering or in the foster care system, important medical and mental health data are often missing and incomplete. Information that is collected by CPS is not accessible to foster families or medical providers and is most often not available when care is sought or obtained. While applicable to social and educational information, medical and mental health information needs to be in a single, portable, and accessible location. Each child entering into foster care (or any conservatorship) should have a readily accessible and comprehensive location where health, mental health, and social information is maintained, and this information should be available to the health providers.

Trauma-informed caregivers : Given the emotional and mental trauma suffered by children entering and in the foster care system, all adults in foster care settings should be training in trauma-informed care and strategies. Adults who are to be foster parents to children within the DFPS foster care system should receive trauma-informed training to better equip them to understand and handle behaviors which the child may display in response to the trauma that resulted in their placement. Given the complex and specialized needs of children in foster care, it is critical that they have access to medical and mental health providers who can provide evidence-based, trauma informed care. This will ideally be delivered in a medical home for the child.

Mental health services : Children who enter foster care, do so because they have been victims of abuse and/or neglect. Given the increased rate of mental and behavioral needs, all children in foster care should receive standardized trauma informed mental and behavioral health screens. They should then have access to the appropriate trauma-informed mental or behavioral health services.

Case management : Given the complex needs and services required for children in foster care, they should have intensive, specialized and individualized case management and service navigation support. As patient navigation has demonstrated improved patient outcomes, all children in foster care should have a dedicated service of case management provided by DFPS available to them.

The articles presented in this issue add to the important body of work and touch on many of these opportunities for system improvements. We hope that these articles and perspectives will spark conversations regarding possibilities for the foster care system and the well-being of children in foster care.


1. Child Welfare Information Gateway. Foster care statistics 2016. 2018; https://www.childwelfare.gov/pubPDFs/foster.pdf . Accessed December 31, 2018.

2. Children's Bureau. Child welfare outcomes 2010-2014: Report to congress. 2017; https://www.acf.hhs.gov/programs/cb/resource/cwo-10-14 . Accessed December 31, 2018.

3. Havlicek JR, Garcia AR, Smith DC. Mental health and substance use disorders among foster youth transitioning to adulthood: Past research and future directions. Children and Youth Services Review. 2013;35(1):194-203.

4. Lohr WD, Jones VF. Mental health issues in foster care. Pediatric Annals. 2016;45(10), e342-e348.

5. Greiner MV, Beal SJ, Nause K, Staat MA, Dexheimer, JW, & Scribano PV. Laboratory screening for children entering foster care. Pediatrics. 2017;140(6), e20163778.

Issue Editor's Point of View



Understanding Health Risks for Adolescents in Protective Custody
Sarah J. Beal, Katie Nause, Imani Crosby, and Mary V. Greiner


Putting Families First: How the Opioid Epidemic is Affecting Children and Families, and the Child Welfare Policy Options to Address It
American Academy of Pediatrics Council on Foster Care, Adoption, and Kinship Care; Douglas Waite; Mary V. Greiner; and Zach Laris


Improving the Health Care of Foster Children Throughout the US: Texas, a Case Example
Nickolas Agathis, Jean L. Raphael, and Christopher Greeley


Pathways to Economic Outcomes and the Impact of Health: Comparing Hispanic and Non-Hispanic Adults after Foster Care
Susy Villegas Ph.D., LCSW; Mónica M. Alzate Ph.D., LCSW; James A. Rosenthal Ph.D.; Kirk O'Brien Ph.D; and Peter J. Pecora Ph.D.

Original Contributions

Invited Commentary

New Research


Development of a Short Trauma Screening Tool (STST) to Measure Child Trauma Symptoms: Establishing Content Validity
Laura L. Maguire RN MS PhD, Estelle Hirsh BA, Jeroan J. Allison MS MD, and Heather C. Forkey MD

Special Content


Household food insecurity positively associated with increased hospital charges for infants
Stephanie Ettinger de Cuba, Patrick H. Casey, Diana Cutts, Timothy C. Heeren, Sharon Coleman, Allison R. Bovell-Ammon, Deborah A. Frank, and John T. Cook