Objective. To determine the reasons for placement of children in foster care, the prevalence of medical findings during initial placement, and the relationship between reason for placement and medical findings. The association between placement reasons and parental substance abuse also was explored.
Methods. Population-based analysis of medical records of 749 children examined at the Child Protection Center in San Francisco from October 1, 1991, to December 31, 1992. Health evaluations consisted of a clearance examination of children during entry into foster care and a comprehensive examination 3 weeks later. Reasons for foster placement included abandonment, neglect, no available caretaker, physical abuse, sexual abuse, and failed placement.
Results. Nearly 50% of children in our study were <6 years of age. Neglect (30%), physical abuse (25%), and no available caretaker (24%) were the most frequent placement reasons, followed by abandonment (9%), failed placement (7%), and sexual abuse (5%). Substance abuse was documented in 30% of parents, 51% when the placement reason was neglect. Medical findings were identified in 60% of children. Among 0 to 6-year-olds, 27% had upper respiratory illnesses, 23% had developmental delay, and 21% had skin conditions; for children 7 to 12 years of age, 32% failed vision screening, 12% had dental caries, and 11% had upper respiratory illnesses; and among 13- to 18-year-olds, 31% failed vision screening and 12% had positive tuberculin skin tests. For younger children, skin conditions were associated with neglect, no available care taker, and failed placement, and developmental delay with neglect and abandonment. For adolescents, history of psychiatric illness was associated with neglect and failed placement. Marks of abuse for all age groups were limited to children who had been physically abused. Three or more diagnoses were identified for ∼20% of children who had been neglected or abandoned or had failed placement, compared with 10% of children who had been either physically or sexually abused.
Conclusions. Specific medical findings associated with reasons for placement provide health professionals with additional information to assess more accurately the health care needs of children entering foster care. As important, screening tests revealed high rates of vision problems and exposures to tuberculosis, warranting earlier and more comprehensive screening. Finally, children who have endured variations of neglect or failed placement may have more health problems than anticipated previously.
The impact of a failed social and family environment on children is vividly demonstrated every year as nearly 500 000 children are placed into substitute care for reasons of abuse and neglect.1-3 The recent increase in this population, 70% from 1985 to 1994, has been attributed to changing patterns in child maltreatment and the epidemic of drug abuse.2-4 In one federal report, 68% of foster placements of young children were attributed to neglect and caretaker absence, and 78% of families from whom children had been removed had at least one parent who used drugs.4
Given that acts of abuse can result in injuries and omissions of neglect in unaddressed health care needs, children placed in foster care are at heightened risk for poor health. The high prevalence of medical and behavioral problems among children in foster care has been documented in numerous studies.5-12 Although health screening of children at entry into foster care is mandated in most states,13 actual implementation may vary by locality. Understanding the association between the reason for foster placement and health problems may assist health professionals in anticipating specific needs.
Although combinations of neglect, abandonment, and caretaker incapacity make up two thirds of the reasons for foster placement, past research has been limited to descriptions of injuries related to physical abuse and genital findings associated with sexual abuse.14-20Recently, a study of children in kinship care demonstrated that children placed for abuse reasons were more likely to have behavioral problems than children placed because of parental incarceration or mental illness.10 Posttraumatic stress disorder has been shown to be more prevalent among children who were sexually abused or had witnessed family violence.21-24 The relationship between neglect and failure to thrive has been documented in the general population.25,26
San Francisco has 2500 children residing in foster care on any given day.27 In 1989, the Departments of Social Services and Public Health established the Child Protection Center (CPC) to centralize the health evaluations of children placed into foster care. The purpose of this study was to analyze the CPC medical records to determine the reasons for placement of children in foster care, the prevalence of health problems identified during evaluation, and the relationship between reasons for placement and medical findings. We also explored associations between reason for foster placement and parental substance abuse, incarceration, and psychiatric illness.
Children placed in foster care in San Francisco are required to undergo a series of health examinations during the first month of placement. Within 72 hours of their removal from homes that are deemed unsafe by Child Protective Services (CPS), children receive a health clearance examination. The purposes of the examination are to identify health conditions that require immediate medical attention and to document evidence of abuse or neglect. Those children who remain in foster care for more than 3 weeks undergo a second and more detailed examination. During this comprehensive examination, resolution of conditions detected initially is determined and screening for vision and hearing deficits, developmental delay, anemia, and tuberculosis is routinely performed.
Most clearance examinations are conducted at the CPC located at San Francisco General Hospital, the only county-owned public hospital in San Francisco, and ∼5% of children are examined at other health facilities. Newborns referred to CPS from the hospital of birth before discharge are enrolled in specialized local programs and are not evaluated at the CPC. The staff at the CPC includes one pediatrician (K.P.C.) and one nurse practitioner (E.W.), both of whom have extensive training in the recognition and management of children who have been abused or neglected. Both of these providers, or pediatric and family medicine residents under their supervision, conduct all clearance examinations and document findings on a standardized form. Examinations by residents are reviewed initially by the attending pediatrician on duty and subsequently by the CPC staff (E.W.). Comprehensive examinations are conducted solely by the CPC staff.
Reason for foster placement is identified and reported by the emergency response child welfare worker (ERCWW) who initially investigates reports of child maltreatment. The ERCWW uses the following categories based on a classification system developed by the Department of Social Services in San Francisco: 1) abandonment, 2) neglect, 3) no available caretaker, 4) failed placement, 5) physical abuse, and 6) sexual abuse. Abandonment is defined as unknown whereabouts of parent or guardian; neglect as child endangerment, child left with unknown caretaker, inadequate housing, inadequate supervision, medical neglect, or child beyond parental control; no available caretaker as parental incarceration, parental hospitalization, or relatives no longer being able to provide care; and failed placement as repetitive absences from foster home or parental relinquishment of foster care responsibilities.
The medical, social, and family histories are initially provided by the ERCWW who obtains the information from any available and willing family historian at the time of removal of a child or children from home for foster placement. The social history includes documentation of substance abuse and psychiatric illness in the child and primary care givers as well as care giver incarceration in a correctional facility. Any psychiatric condition that required treatment with medications or hospitalization is reported as history of psychiatric illness. To address potential inaccuracies and incompleteness of such data, additional history and corroboration are obtained routinely by the CPC staff from past CPC records and medical records for the ∼60% of children who received previous medical care at San Francisco General Hospital.
We analyzed the medical records of 749 children examined at the CPC during the 15-month period from October 1, 1991, to December 31, 1992. Our subject population included all children referred to the center by CPS. The computerized medical data base at the CPC consisted of demographic characteristics, reasons for foster placement, social history, and health problems identified during the examinations. Demographic variables included sex, age, race, and ethnicity. Age was categorized into three groups: 0 to 6 years, 7 to 12 years, and 13 to 18 years. Only one reason for foster placement was provided for each examination; when reasons differed for a subsequent examination, only the first was included in the analysis. Medical findings were identified based on the combination of medical history, physical examination, and screening and laboratory tests. Individual diagnoses were grouped into nine nonexhaustive categories (Table1). Psychiatric and behavioral problems were excluded from the analysis because standardized assessment tools, critical in identifying such problems, were not used systematically.8,28,29 Screening test results were available only for the smaller proportion of subjects (n = 308) who received the comprehensive examination.
The Denver Developmental Screening Test was used to determine developmental delay for children ≤6 years of age. Failure to attain milestones achieved by 90% of children of the same chronologic age in any of the four categories—gross motor, fine motor, language, and social skills—was considered developmental delay. Developmental testing was conducted only during the comprehensive examination because of the need for a consistent and experienced evaluator and a comfortable examination environment. The foster parent who accompanied the child to the examination could also provide information about behavior during the preceding 3 weeks of foster home care.
The Snellen vision chart and pure-tone audiometric hearing tests were used to evaluate children ≥3 years of age. Abnormal vision was defined as visual acuity 20/50 or worse in either eye for children ≤6 years of age and 20/40 or worse for children >6 years of age.30 Children did not wear glasses during the screening test. Abnormal hearing was defined as no response in either ear to the screening level of 25 dB at any one or more frequencies of 1000, 2000, 3000, or 4000 Hz.30 The diagnosis of anemia was based on hemoglobin values <10.5 mg/dL for children 6 months to 2 years, <11.5 mg/dL for children 2 to 12 years, and <12 mg/dL for girls and <13 mg/dL for boys >12 years of age.30 The Mantoux test was administered to screen for tuberculosis, and skin responses were evaluated after 48 to 72 hours by a nurse or physician at San Francisco General Hospital.
The χ2 statistic was used to analyze relationships between categorical variables. Significance of association between reasons for placement and medical findings was determined by age group. Statistical analyses were conducted using Statview V4.0 software (Abacus Concepts, Inc, Berkeley, CA).
Demographics and Health Care Use
Equal numbers of male and female children were examined at the CPC. The average age of children in our sample was 7.3 years, with nearly half <6 years of age. The majority of children in our study were African-American, followed by Hispanic and white (Table2).
The 749 children placed in foster care and evaluated at the CPC had 1043 examinations, 70% of which were clearance and 30% comprehensive. Fifty-nine percent of the children underwent clearance examinations only, whereas 39% underwent both clearance and comprehensive examinations and 2% underwent comprehensive examinations only.
Reason for Foster Placement
Neglect (30%), physical abuse (25%), and no available caretaker (24%) were the most common reasons for foster placement among children examined at the CPC (Table 3). Only eight children (1%) had more than one reason for placement. Although nearly two thirds of the children who had been sexually abused were female, both sexes were represented equally for all other reasons. Reason for foster placement was related to age, with more than half of young children age 0 to 6 years more likely to be neglected, with no available caretaker, and abandoned, and a majority of adolescents age 13 to 18 years having failed placement (P < .001). Neither physical nor sexual abuse was associated with a particular age group.
Substance abuse, incarceration, and psychiatric illness were identified in 30%, 9%, and 5% of parents, respectively (Table4). Among parents who used drugs, 15% had been incarcerated and 4% had psychiatric illnesses. The rate of parent substance abuse was 51% for neglected children and lower for children with other reasons for placement (P < .001). Incarceration of parent was associated with no available caretaker and failed placement (P < .001).
Examinations at the CPC revealed health problems for 451 (60%) children placed in foster care. Overall, 19% had upper respiratory illnesses and 15% had skin conditions, followed by 6% each with marks of abuse and asthma. Among the children who had comprehensive examinations, 20% were identified with myopia and 12% with developmental delay.
Sixty-two percent of young children were determined to have one or more medical problems (Table 5). Upper respiratory illnesses were most common, followed by developmental delay and skin conditions. Otitis media made up 55% and upper respiratory infection made up 40% of upper respiratory illnesses. Among skin conditions, 64% were diaper dermatitis and 14% tinea infections.
Medical findings were identified in 53% of school-aged children 7 to 12 years and 63% of adolescents. For school-aged children, one third had abnormal vision (predominantly myopia), 12% had dental caries, and 11% had upper respiratory illnesses. Marks of abuse were documented in nearly 10% of children. Among adolescents, one third also were myopic, followed by 12% with positive reactions to the tuberculosis skin test, 12% with skin conditions, and 11% with upper respiratory illnesses. In contrast to younger children, 40% of adolescent skin conditions were acne and 25% tinea corporis. Thirteen adolescents were identified with gynecologic conditions, five with vaginitis and four with pregnancy.
Medical findings were associated with reasons for foster placement (Table 6). For young children, skin conditions were found more frequently among children who had been neglected, had no available caretaker, or had failed placement (P < .05). Marks of abuse were limited to physically abused children (P < .001) and developmental delay to neglected or abandoned children (P < .01). Among school-aged children (P < .001) and adolescents (P < .001), marks of abuse also were confined to those who had been abused physically. History of psychiatric illness was more frequently elicited from adolescents who had been neglected or who had failed placement (P< .05).
Although the proportion of children with any medical finding did not vary by reason for placement, the mean number of diagnoses was associated with reason for placement. Among children with any medical finding, three or more diagnoses were identified for 22% of children who had been abandoned, 21% who had failed placement, and 18% who had been neglected, compared with 11% of children who had been physically abused and 6% who had been sexually abused (P = .022).
Neglect, no available care taker, and abandonment are variations of an inability of families to provide adequate care for their children. Together, they totaled two thirds of the reasons for placement of children in foster care in San Francisco. Recent studies have documented similar or higher proportions as placement reasons.11,12 Inability to parent, however, does not occur in a vacuum. In our study, a history of parental substance abuse, incarceration, or psychiatric illness was present in nearly 40% of families. More than half of children who had been neglected had parents who used drugs, and nearly one third of children with no available caretaker had parents who were incarcerated. According to one survey of state public agencies, children in foster care whose parents have problems related to alcohol and other drugs were more likely to experience multiple placements and to stay longer in foster care than were other children.31 Although the need for intervention is clear, foster care may be a costly and inefficient solution to the problems of substance abuse and other social ills.32,33
Our analysis of CPC medical records of children placed in foster care in San Francisco determined the prevalence of medical findings to be 62% for young children 0 to 6 years of age, 53% for school-aged children 7 to 12 years of age, and 63% for adolescents 13 to 18 years of age. These figures are consistent with the range of 66% to 92% reported in other studies.5,6,8,9,11,12 We identified acute problems more frequently than chronic conditions. The overall rates of the most common problems—respiratory illnesses and skin conditions—were 19% and 15%, respectively; among young children, they were 28% and 21%. The prevalence of asthma, the leading chronic condition, was 6% and similar to the figure for the general population of children.34
Among children receiving comprehensive examinations, 20% overall and nearly one third of older children were identified with vision problems, namely myopia. Although consistent with findings from previous studies of children in foster care,5,6,9,11 our rates for adolescents are higher than the 24% reported for the general adolescent population.35 Although the prevalence of conditions associated with vision problems, such as neurologic and congenital disorders, is also higher among children in foster care, the extent of their contribution to myopia has not been described clearly.5,7,9,36,37 In the meantime, comprehensive vision evaluation and provision of corrective lenses must be encouraged, especially given the poor school achievement common among children in foster care.6,38
The 12.3% tuberculin test positivity rate among adolescents is substantially higher than figures available for healthy adult populations, ranging from 2.5% among US Navy recruits to 6.1% among applicants to a department of corrections.39,40 With high rates of parental substance abuse, children placed in foster care are significantly more likely than the general population to be exposed to adults with at least one risk factor for tuberculosis.41,42A majority of children in our study, however, were not screened for tuberculosis because they did not remain in foster care for >3 weeks. Results strongly suggest that all children should be screened routinely before entry into foster care to ensure the timely identification of exposure, determination of infected adults, and protection of foster families and child welfare workers.
Our study uncovered several relationships between reason for foster placement and medical findings. One quarter of young children who had been neglected, without available caretaker, or had failed placement were identified with skin conditions. When a competent parent is missing, the detection of untreated or persistent dermatologic problems common among toddlers, such as diaper dermatitis and fungal infections, may not be unexpected. Although other researchers have also demonstrated higher rates of skin conditions among younger children in foster care,9,11,12 detailed descriptions of their severity and chronicity are lacking. Although additional studies are needed, documentation of skin findings and their resolution may provide health professionals with an additional measure for assessing both severity of parental neglect and quality of ongoing care.
Developmental delay was identified in one third of young children who had been neglected and in one quarter who had been abandoned. Although the results of developmental assessment conducted during a period of psychosocial stress may be inaccurate, there is no reason to consider a differential impact based on reason for placement. The relationship demonstrated between neglect and developmental delay, however, requires interpretation. Children not exposed to early and sufficient infant stimulation may fail to achieve timely developmental milestones.43-45 Appropriate resources, however, may be especially lacking among families whose children are at risk for developmental delay (eg, premature birth, exposure to illicit drugs in utero).46-48 The risk factors for developmental delay, furthermore, overlap with those for foster placement. Finally, children who become severely delayed may further exhaust the financial, social, and emotional resources of caretakers. Although our study does not elucidate the temporal and causal relationships between developmental delay and neglect, our findings suggest that early and effective interventions for children at risk for delay may not only improve developmental outcomes but possibly prevent foster care placement. As important, children with developmental problems are those most likely to experience difficulties in finding permanent placement.49,50
Marks of abuse were limited to children of all ages who had been physically abused. Even with an additional 6% of children identified with other injuries that may have resulted from physical abuse, however, 70% of children demonstrated no detectable physical signs. Pediatric and family medicine residents who conducted these examinations may have failed to identify accurately or document minor injuries that did not require treatment. More likely, the decision to place children in foster care may have relied more heavily on the cumulative history, rather than on recent physical evidence, of physical abuse. Past CPS reports, however, were not available to the CPC to substantiate such a theory.
History of psychiatric illness was elicited from 6% of adolescents. This figure cannot begin to approximate the total burden of mental health problems for children in foster care. If standardized behavioral assessment tools had been used consistently, we believe that the rates of behavioral and emotional problems would have fallen within the range of 23% to 84% reported among children in foster care5,6,8,9,11,51 Even with our limited data, however, we demonstrated an association with reason for foster placement. A history of psychiatric illness was documented in nearly one fifth of adolescents who had been neglected or had failed placement and in none placed for other reasons. Given that medical treatment or hospitalization was required to document this history, psychiatric illnesses may have been severe enough to have preceded, and even contributed to, foster placement failures. Alternatively, chronic neglect and repeated placement failures may have exacerbated such illnesses. Additional research based on comprehensive mental health evaluations for children placed in foster care will help to unravel these complex relationships and to appropriately address mental health needs.
Contrary to accepted dictum, neglected and abandoned children and those who have failed placement have more diagnoses and may suffer from worse health compared with abused children. Among a variety of factors, parental substance abuse is one that may provoke poor outcomes when families cannot provide adequate care for their children. In our study, a history of parental drug use was documented in 51% of children who had been neglected, almost twice the rate for children who had been sexually abused and more than three times the rate for children who had been physically abused. Failed placement, on the other hand, may represent multiple placements with repeated disruptions of health services or particularly difficult behavioral or emotional problems that preclude permanent or long-term placement. Although intense media coverage and public outcry have been associated with incidents of abuse,52,53 the increasing proportion of foster placement attributable to other reasons provides additional impetus to explore further the relationship between different types of maltreatment and health outcomes.
One barrier to the study of the impact of child maltreatment is the lack of a uniform classification system for either type of maltreatment or reasons for foster placement. Although the National Center on Child Abuse and Neglect recommends the use of four categories of maltreatment—physical abuse, child neglect, sexual abuse, and mental injury—researchers have not adapted this classification system.54 None of four recent studies of children in foster care used this system; in fact, each used a different classification scheme.8-11 In our study, overlapping types of child maltreatment, such as neglect, abandonment, and no available caretaker, may have diminished our ability to demonstrate significant findings. Furthermore, only one reason for placement was designated by the ERCWW for each child, potentially resulting in an oversimplification of the complex connection between placement and medical findings. A recent study reports that most children may be subjected to combinations of abuse and neglect.55
The results from our study should be interpreted with additional caution. Because the CPC database did not capture the entire population of children placed in foster care in San Francisco, there may be inaccuracies in the figures for both reason for foster placement and medical findings. Our results, however, were consistent with what has been reported previously.8,9,11,12 Information obtained by the ERCWW, especially given the stressful nature of a CPS investigation, is likely to be incomplete. We may have underestimated factors related to placement reasons such as parental substance abuse. Because both trained staff professionals and physicians-in-training conducted the examinations, physical findings may vary from provider to provider.
Only 40% of children in our study underwent both a clearance and a comprehensive examination, with the remaining majority receiving only a clearance examination. Accordingly, more data were most likely available for some children and not for others, raising the potential for ascertainment bias. The degree to which such a bias might have affected our study results could not be determined. For some children, especially those who failed placement, an additional problem requires discussion. These children may have had multiple previous referrals and placements that contributed to current health. The CPS, however, did not provide past data to the CPC, thus limiting both critical information and ascertainment bias. We also did not consider socioeconomic status, which may have had a modifying effect on the development of a variety of illnesses.56 Finally, the population of children placed in foster care in San Francisco may not be comparable with those in other cities. The decision to place children in foster care differ from county to county. Demographic characteristics such as age, sex, and ethnicity, however, were comparable with populations investigated in other recent studies.8,9,11,12
Children in foster care exhibit health problems that reflect the particular reason for their placement. Younger children who are neglected tend to have higher rates of skin conditions and developmental delay; those who are physically abused have injuries consistent with abuse; and adolescents who failed placement have psychiatric problems. These findings help to delineate the impact of maltreatment on child health and provide health professionals with potential markers to assess the effectiveness of both health and foster care interventions. The high overall rates of vision problems and tuberculin skin test positivity warrant not only correcting poor vision but also requiring earlier provision of screening tests. Given the high prevalence of parent substance abuse among children placed in foster care, investment in the prevention and treatment of substance abuse among adults with families must be given priority. Mandated health screening and improved medical record systems are only the first and necessary steps for the early identification and effective treatment of health problems among children placed in foster care.
We thank Dr Moses Grossman for his direction and support during the initial conception of this study, Dr Robert H. Pantell for his insightful reviews of the manuscript, and the four anonymous reviewers for their discerning comments.
- Received August 12, 1996.
- Accepted June 27, 1997.
Reprint requests to (J.I.T.) Department of Pediatrics, Campus Box 0374, University of California San Francisco, San Francisco, CA 94143-0374.
- CPC =
- Child Protection Center •
- CPS =
- Child Protective Services •
- ERCWW =
- emergency response child welfare worker
- ↵US House of Representatives, Select Committee on Children, Youth, Families. No Place to Call Home: Discarded Children in America; 1989. Washington, DC: US Government Printing Office
- ↵Tatara T. US Child Substitute Care Flow Data for FY 1993 and Trends in the State Child Substitute Care Populations (VCIS Research Notes). Washington, DC: American Public Welfare Association; August 1995; Report 11
- ↵Kilborn PT. Priority on safety is keeping more children in foster care. New York Times. April 29, 1997; A1
- ↵Foster Care: Parental Drug Abuse Has Alarming Impact on Young Children. Washington, DC: US General Accounting Offices; April 1994. Publication GAO/HEHS-94-89
- Schor EL
- Moffatt MEK,
- Peddie M,
- Stulginskas J,
- Pless IB,
- Steinmetz N
- Chernoff R,
- Combs-Orme T,
- Risley-Curtiss C,
- Heisler A
- Weinstein J,
- La Fleur J
- Yeoh C,
- Nixon JW,
- Dickson W,
- Kemp A,
- Sibert JR
- American Academy of Pediatrics, Committee on Child Abuse and Neglect
- Hobbs CJ,
- Wynne JM,
- Thomas AJ
- McCann J,
- Voris J
- McCann J,
- Voris J,
- Simon M
- Casey PH,
- Bradley R,
- Wortham B
- ↵The Health and Well-Being of Children in San Francisco 1991. San Francisco, CA: Family Health Bureau and Office of Budget and Planning, San Francisco Department of Public Health; 1991
- ↵Child Health and Disability Prevention Program: The Medical Guidelines. Sacramento, CA: CHDP, Department of Health Services; 1982
- Lewis MA,
- Leake B,
- Ciovannoni J,
- Rogers K,
- Monahan G
- ↵Sperduto RD, Siegel D, Roberts J, Rowland M. Prevalence of myopia in the United States. Arch Ophthalmol.MDNM 1983;101:405–407
- ↵Edwards WC, Price WD, Weisskopf B. Ocular findings in developmentally handicapped children. J Pediatr Ophthalmol Strabismus. 1972;9:162
- Landau L,
- Berson D
- American Academy of Pediatrics, Committee on Early Childhood, Adoption and Dependent Care
- ↵Centers for Disease Control and Prevention. Screening for tuberculosis and tuberculosis infection in high-risk populations. Recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR. 1995;44(RR11):19–34
- Sandermann H,
- Madsen KS,
- Friis-Hansen B
- Azuma SD,
- Chasnoff IJ
- ↵Dugger CW. Fatal beating points up a system in crisis. New York Times. September 9, 1992; A1, C19
- ↵Alvarez L. After death of 6-year-old girl, report shows system's collapse. New York Times. April 9, 1996; A1, B15
- ↵DePanfilis D, Salus MK. A coordinated response to child abuse and neglect: a basic manual. National Center on Child Abuse and Neglect. Washington, DC: US Department of Health and Human Services; 1992. US DHHS Publication (ACF) 92-30362
- Copyright © 1998 American Academy of Pediatrics