Helping the most vulnerable: Kids in foster care

On any given day in the U.S., there are more than 400,000 children in foster care. About 30,000 of these children are right here in Texas. Close to 8,000 of these children are in the Harris County region alone. You likely interact with children in foster care or their current caregivers in your daily life, in clinic for those in pediatrics, or within your community or places of worship. May is National Foster Care Month, a time to recognize that we can each play a part in enhancing the lives of children and youth in foster care.


Children in foster care are a uniquely vulnerable population with increased mental health and developmental needs due to high rates of complex trauma that arises from adverse childhood experiences, such as child abuse and/or neglect, exposure to domestic violence, and impaired parenting that occurs prior to and sometimes while in foster care.

They also have higher rates of some physical health problems. Chronic physical health problems are prevalent in children entering foster care, where up to half of children have at least one chronic health condition compared to less than 20% of children who are not in the child welfare system.

What can be done to improve the child welfare system and help make the lives of foster care children better? Here are a few ideas:

Keep families together.
When a child enters the foster care system they are often separated from their family. Research has shown that in fact keeping families together leads to better outcomes for children. Investment in child abuse prevention strategies is key. We also need to support other programs like Plans of Safe Care that help parents in need and may decrease the number of families referred to child protective services or an ongoing open child welfare case.

State funding for The Families First Prevention Services Act (FFPSA).
In February 2018, Congress passed FFPSA as a part of the Bipartisan Budget Act. Although the effective date for the act was Oct.1, 2019, Texas elected to delay implementation until Oct. 1, 2021. This landmark legislation aims to shift focus and investment nationwide toward family-based prevention services and, to the extent possible, the placement of children in family environments and the least restrictive settings necessary.

As a pediatrician, I know that education and support to caregivers is critical because it helps them better understand child development, foster healthy coping mechanisms, and use appropriate discipline techniques, all of which help break intergenerational cycles of abuse and neglect. FFPSA provides an opportunity for states to enhance efforts in child abuse prevention by allowing states to draw down new federal matching funds to prevent the need for a child to enter foster care. FFPSA dollars will support evidence-based and trauma-informed mental health and substance use services as well as in-home parenting skill-based programs.

Address racism and bias, which is systemic within the child welfare system.
Non-white children are more likely to end up in foster care (Black children are twice as likely and native American children are three times more likely). Racial disparities exist in reports of abuse and neglect to Child Protective Services (CPS), confirmed CPS cases, and removals. African American children make up 19.6% of reports to CPS, 18% of the confirmed child abuse/neglect cases, and 20% of removals, despite comprising only 11% of the child population in Texas.

When compared to Anglo-Americans, the average length in care was longer for African American children for all permanency outcomes, including family reunification, relative care, relative/non-relative adoption and emancipation. Similarly, the length in care for Hispanics was longer for all outcomes except relative adoption. Black children are also more likely to spend time in congregate settings, such as group homes. Nationally, while 23% of children in foster care are Black, they make up 30% of children in congregate care placement.There is a real need to implement anti-racism training and enact policies practices that promote racial equality at all levels of the system. We also need to focus on reforming the criminal justice system. Children with incarcerated parents have a much higher likelihood of entering the child welfare or criminal justice systems. Efforts to reduce penalties for drug offenses and other nonviolent crimes are needed.

Funding urgently needed.
We need more federal and state funding to support families and communities in need – food assistance programs, improving housing stability, domestic violence prevention, mental health services and substance abuse treatment services.

How can you make a positive impact on a child in foster care?
  • Become a foster parent. If you have the time and resources, there is always a dire need for more foster homes.
  • Volunteer as a court-appointed special advocate, or guardian ad litem. In this role, you serve as an advocate for a child in the child welfare system both in and out of the courtroom.
  • Donate to an organization serving children in foster care, such as Texas CASA or organizations focused on training such as Fostering Family.

While there is much to be done to improve the broken child welfare system, I remain hopeful. I recall the story of one of my long-term patients, a teen recently placed in a foster-to-adopt placement where he is flourishing. He experienced abuse and neglect at the hands of his previous foster parent. In my most recent visit, in front of his new foster mom and his younger siblings, he said “Dr. Keefe, thank you for having my back. No seriously, you were the only one who had my back. Thank you.”

-By Rachael J. Keefe, M.D., MPH, FAAP, assistant professor of pediatrics at Baylor College of Medicine and the Section of Public Health Pediatrics, Texas Children’s Hospital, medical director of the Texas Children’s Foster Care Clinical Service, co-chair of the Texas Pediatric Society’s Foster Care Committee, and member of the American Academy of Pediatrics (AAP) Council on Foster Care, Kinship Care and Adoption (COFCAKC) Executive Committee


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