March 2015, VOLUME135 /ISSUE 3

For Optimal Outcomes, Children Belong in Homes

  1. Clarissa C. Kripke
  1. Director of Developmental Primary Care, University of California, San Francisco

In the Clinical Report “Out-of-Home Placement for Children and Adolescents With Disabilities,” Friedman and colleagues1 review options for placing children with disabilities in congregate care settings. However, the report omits discussion of the best interests of the child in selecting out-of-home options and fails to review and prioritize noninstitutional models of care. When families of origin are unable to provide adequate care, children with disabilities retain their right to receive care in the least restrictive setting. Like all children, children with complex disabilities benefit from family and community life. Therefore, it is a national priority to reduce the number of children and youth with disabilities aged 21 years and under living in congregate care residencies.2 It is also a national priority to increase the proportion of people with disabilities who participate in social, spiritual, recreational, community, and civic activities to the degree they wish.3 This clinical report undermines these important priorities by lowering the bar to institutionalizing children. The report does not address the negative impact of institutional care on growth and development of children with disabilities beyond a few narrow medical outcome measures.

As reviewed in the Clinical Report “Parent–Provider–Community Partnerships: Optimizing Outcomes for Children With Disabilities,” with proper support most children with disabilities thrive at home.4 Families who lack the resources to care for their children with medical and behavioral needs can be referred to their state protection and advocacy organization for assistance with exercising their right to community services and supports. These rights were established through the Supreme Court’s decision in Olmstead v. L.C. Families struggling with social stigma, guilt, isolation, or feelings of inadequacy can be referred to their local parent information center or for individual counseling. When out-of-home placement is the best option for a family, homelike settings such as host family, voluntary foster care, and small group homes should be explored before long-term care settings with 4 or more residents are considered.

Pediatricians have an important role in advancing and implementing public policy to ensure that all children enjoy the benefits of full inclusion and access to community life, regardless of their medical, behavioral, or support needs.


  • E-mail: kripkec{at}
  • Conflict of Interest:

    None declared.


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