TABLE 2

Developmental Tasks and Issues Specific to Adopted and Foster Children

Age and Developmental StageErikson’s Psychosocial Stages of Development88Issues That May Be Intensified for Adopted and Foster ChildrenStrategies for Families and Pediatricians
Birth to 16 moTrust versus mistrustDifficulty or failure to develop a trusting, reliable attachment to caregivers
Children may present with feeding problems, anxiety, depression, aggression, sleep disorders, and lack of trust56
Educate caregivers of the need to provide a consistent, sensitive, and responsive environment
Caregivers should be vigilant for behavioral dysregulation that can be a sign of previous trauma and toxic stress36
18 mo to 3 yAutonomy versus shame and doubtA child’s emerging self-centered perception of the world can become fragmented from experiences of multiple caregivers, previous neglect, and physical or sexual abuseCaregivers should be aware of the manifestations of early childhood adversity and toxic stress56,57
Create a highly structured, calm environment that provides a feeling of safety and security
Address a child’s questions and fears with acknowledgment tempered with reassurance of the child’s current safety
Be vigilant for developmental delays and behavioral problems, especially in cases of known or suspected prenatal alcohol or drug exposure and in such cases facilitate referral for evaluation for fetal alcohol spectrum disorders
Refer to early intervention for developmental delays and behavioral concerns
3–5 yInitiative versus guilt
Problem-solving; attempts to understand permanency and past and current living arrangements
Children who have experienced trauma or been placed with multiple caregivers may exhibit anger, withdrawal, aggression, or sadness because of feelings of insecurity about their environment or caregivers
Children who come into families by foster care or adoption experience loss in multiple areas of their life; loss should be viewed as a form of trauma and may manifest in variety of ways depending on the child’s developmental level, the type of placement (temporary versus permanent), familiarity of surroundings and support systems8285
Keep a daily, consistent routine
Understand a child’s current concerns and behaviors in the context of their past experiences and meet these challenges with acknowledgment and reassurance
Validate a child’s feelings while setting limits on problematic behavior
Refer to mental health services when appropriate
Refer for speech and other developmental or behavioral problems
Consider referral to developmental-behavioral pediatrician and/or referral for evaluation for fetal alcohol spectrum disorders in cases of developmental or behavioral challenges
Provide opportunities to nurture intellectual curiosity by allowing preschoolers to explore their environment through imaginative play and social engagement
Encourage preschoolers to plan and participate in new activities of their own choosing within the bounds of a safe environment
Middle childhoodIndustry versus inferiority
Peer groups have increased influence over a child’s self-esteem
Fostered or adopted children may experience low self-esteem and feelings of inferiority or rejection as they become aware of their differences from their peers. Such issues may be especially difficult for children placed in homes of a different racial or cultural background
In addition to loss of their family of origin, fostered children may experience the loss of friends, surroundings, culture, and disruption of past routines
Caregivers can help their child integrate past experiences into their current life
Caregivers can help a child begin to understand how current feelings and thoughts may be related to past experiences while grounding the child to their present life circumstances
Refer to mental health services when appropriate
Refer for educational support services if indicated
Consider referral to developmental-behavioral pediatrician and/or referral for evaluation for fetal alcohol spectrum disorders in cases of learning and/or behavioral challenges
Caregivers can be encouraged to educate their child about their cultural history while being sensitive to nonverbal clues that they communicate about race and cultural differences
AdolescenceIdentity versus role confusion
Autonomy
Abstract thought; concepts like adoption and permanency may be internalized and adolescents might go through an intense period of self-reflection in an attempt to define their identities. As adolescents develop and begin the task of separation and individuation, permanency issues commonly become important, changing relationships between the adolescent and family
Early life trauma and toxic stress can worsen as a child moves from childhood to adolescence, especially when compared with peers who have had more stable childhoods
Adopted adolescents or adolescents in foster care often struggle to integrate their past life into their current life and their future
Adolescents may challenge authority within and outside the family, which may result in conflict; Youth may “test” caregivers by challenging their commitment to their relationship
Risk-taking or unhealthy peer relationships can place adolescents at high risk for substance use, chronic truancy, and/or involvement in the juvenile justice system; such behaviors are sometimes precipitated by contact with or identification with birth parents who may have had similar difficulties
Caregivers should be aware of the manifestations of past traumatic events and losses and meet challenging behaviors with understanding but age-appropriate limit setting
Encourage diary and creative writing or other art forms as a path for integrating past and present experiences into a life story
Ensure appropriate support services are provided in school
Refer for mental health or substance use treatment services when indicated
Consider referral for evaluation for fetal alcohol spectrum disorders
Pediatricians can screen for and directly address risks for substance use, depression, suicidality, and criminal behavior in one-on-one conversations with the adolescent
In cases in which adolescent risk-taking behavior becomes a risk to an adolescent’s future or placement stability, caregivers can consider pursuing a person-in-need-of-supervision petition in family court
Young adulthood86Experiment and exploration: love, work, and worldviewsHousing instability
Educational dropout
Unemployment
Lack of trust, expectation of failure in life trials, and social acceptance
Engagement in criminal activities
Support transition with extension of foster care to age 21 y
Supportive housing
Job placement
Funding for college opportunities
Social networks and mentoring