Child welfare: Now that we know better, let’s do better

Contemporary PEDS JournalMay 2024
Volume 40
Issue 04

Improvement in access to mental health resources for children would decrease vicarious trauma of foster parents and social workers via improved living and working conditions.

Child welfare: Now that we know better, let’s do better | Image Credit: Author provided

Child welfare: Now that we know better, let’s do better | Image Credit: Author provided

“We work for two different child welfare agencies. We don’t understand. Why can’t we get anyone to help us?” The new foster parents sat in my office harried and overwhelmed.

This couple had worked in and around child welfare for years. They knew of the shortage of foster parents and had made the thoughtful and conscious decision to become foster parents instead of having children of their own. They were excited just one month earlier when they welcomed a six-year-old girl and three-year-old boy who had come from a home where their mother was cooking methamphetamines and trading sex for money. The children had been raised by older children in the home. Neither were toilet-trained, and both used profanities regularly in their dialogue.

The Reality of Parenting Foster Children

The new foster parents were “trauma-informed” and had had appropriate trauma-based relational intervention training. They understood where the maladaptive behaviors were rooted. But understanding behaviors does not translate into everyday life when people have other real-life demands.

“When we take her to school, she is screaming and yelling obscenities, punching, spitting and kicking. We can’t even unlatch the car seat to get her out of the car. The school says we have to take her home. We are missing a lot of work. Agencies tell us the school should offer services. The school won’t even let her come! You gave us a list of clinics that take Medicaid, but we called all of them and they are either capped or have a three to six month waiting list!”

Why Disruption Really Happens

One month later, they were back in my office. “We can't do this anymore. We can’t go anywhere. We can’t sleep at night because she gets up and gets into things, even with the special locks. This is affecting our marriage...”

The placement was disrupted, and the child was re-traumatized. But she was not the only one who was traumatized. The foster parents were traumatized, as were the case workers who were “sure” these parents would be the ones to heal the children through “safe, stable and nurturing relationships.” Even more tragic is the fact that this cycle will likely repeat itself over and over with the child playing the same starring role in the same drama with other supporting cast members that will be traumatized as well. And we wonder why child welfare never has enough foster parents, child welfare workers, and support staff.

As a pediatrician who is a foster care and adoption advocate, the story is not unusual for me. I have seen it repeatedly over the last 25 years. What is unusual is that these parents were more informed and well connected in the mental health and child welfare industry than any foster parent I had cared for to date. And for this couple, it was the first time their eyes were opened to the real problem: lack of access to mental and behavioral healthcare for foster and adoptive children.

The Foster Care Shortage

Research consistently shows the demand for foster homes exceeds the supply by 30% nationally. Between 30% and 50% of foster parents drop out after the first year of fostering.1 The average length of employment in child welfare agencies is less than 2 years and some agencies estimate turnover rates as high as 60%. Reasons cited include high caseloads, burnout, lack of support, low pay and rigid regulations.2 However, the real problem, however, is NOT a lack of foster parents, a lack of child welfare workers or even a lack of trauma-informed training. The real problem is the lack of timely and appropriate mental health services for these children.

The Root of the Problem

Multiple studies have linked exposure to trauma in childhood to poor outcomes, from emotional dysregulation to homelessness and justice system involvement. According to the National Child Traumatic Stress Network, a traumatic event is a dangerous or distressing experience outside the range of typical human experience that overwhelms an individual’s capacity to cope.3 Children find themselves in child welfare because of physical abuse, sexual abuse, emotional abuse, or neglect, all of which comprise trauma. The Adverse Childhood Experiences study links childhood trauma proportionally to adverse mental, physical, and emotional outcomes in adulthood.4 Complex trauma is exposure to traumatic experiences over time and multiplies the risk for adverse outcomes. Child maltreatment involves exposure to interpersonal trauma, is frequently complex, and is one of the strongest risk factors for future mental, emotional, and behavioral problems in later life. Unfortunately, many foster children continue to experience trauma in the system.

Research by Clark et al. (2020) sought to understand the relationship between childhood trauma and placement stability.4 To this end, they recruited four midwestern foster care agencies and had caseworkers administer the Childhood Report of Post Traumatic Symptoms (CROPS) within 120 days of program entry. They found that half the children had a CROPS score of 19 or higher which signifies significant trauma symptoms. When controlling for demographic characteristics, these children had a 46% higher chance of experiencing placement instability. It should not be surprising, then, that child-welfare involved youth are at substantial risk for adverse outcomes, including academic failure, homelessness, and justice system involvement.5-7

When assessing foster care outcomes through a trauma lens, it becomes clear that the impact of the abuse and neglect leaves a lasting effect on these individuals. Only about 50% of foster children graduate high school by the age of 19 years old, and only 1-3% of former foster children ever graduate from college. Over 81% of males who age out of foster care are justice-involved. Approximately 72% of girls who age out of foster care have been pregnant by the age of 19 years old. Over half of all foster children who age out are unemployed at the age of 26 years old.8 A study byNarendorf, et al., of homeless young adults in Oregon revealed that 20% had been involved in foster care, 18% in the justice system, and 18% in both. Dually involved young adults were also at increased risk for trading sex, substance abuse, and adult arrest.6 It is not surprising, then, that recent research seeking to understand the experiences and glean recommendations from former foster youth cited healing and dealing with trauma as the number one priority. In fact, they understood unresolved trauma as the root cause of many of their struggles and claim healing from trauma is not only a low priority in foster care, but it is not even named.9

We Cannot Ignore Mental Illness

The medical community has long reported on the heritability of mental illness, a prominent risk factor for child welfare involvement. In fact, most psychiatric disorders are genetically inherited, including alcohol dependence, schizophrenia, bipolar disorder, ADHD, autism spectrum disorder, major depressive disorder, obsessive-compulsive disorder and anorexia nervosa.10,11 A recent advancement in neuroscience is epigenetics, or the turning off or on of genes that might confer resilience or fragility.12 Other advances in neuroscience are functional neuroimaging techniques such as SPECT, fMRI and qEEG brain mapping. Yet, child welfare continues its focus on changing the environment of children to help them develop to their full potential. These functional neuroimaging techniques offer objective, concrete data to support the biological underpinnings of drug abuse, ADHD, depression, anxiety and a myriad of other problems that often lead to child welfare involvement, especially when combined with trauma.

In particular, qEEG brain mapping offers several unique advantages. It is non-invasive, inexpensive, and can be learned and utilized by licensed mental health professionals. Most importantly, qEEG brain maps can be used to guide neurofeedback, an evidence-based modality to ameliorate the symptoms of complex PTSD and anxiety.13,14 Therefore, neuroscience has the potential to make profound contributions to social work practice in child welfare. Child welfare policy must incorporate the newest findings in neuroscience to best care for children and families that find themselves involved in the system.

Time to Do Better

Maya Angelou once said, “Do the best you can until you know better. Then when you know better, do better.” According to the Department of Health and Human Services website, the Children’s Bureau’s mission is to partner “with federal, state, tribal, and local agencies to improve the overall health and well-being of our nation’s children and families.” The Adoption and Safe Families for Children Act (ASFA) of 1997 uses legal permanence within 2 years of entry as the key measure of child well-being. Thus, legal permanence is a surrogate measure for “overall health and well-being" because of the widely accepted belief that the family is the best place for children to form safe, secure connections. While a stable loving home is necessary for this outcome, it is not sufficient. It is analogous to placing a patient with a serious bacterial infection in the hospital with no medicine. The patient could have the best doctors and nurses, but this will not suffice for treating the infection. The patient is still at high risk for morbidity and mortality. Legal permanence as an outcome measure causes hyperfocus on one goal with blindness to more important “non-goals” such as mental, emotional, and behavioral health and overall well-being.

The core issues foster children face, trauma and mental health issues, are not in proper focus, so when externalizing behaviors make it difficult for foster families to cope, no concrete solutions are offered which leads to placement failure. This is a cycle that repeats itself over and over, compounding these children’s trauma. Witnesses to this trauma are foster parents and social workers, which leads to vicarious trauma and high drop-out rates for both. A shift in child welfare policy at the macro- level that targets healing childhood trauma and addressing underlying mental health issues, rather than permanency, would shift funding at the mezzo- level to mental and emotional health interventions. At the micro-level, improvement in access to mental health resources for children would decrease vicarious trauma of foster parents and social workers via improved living and working conditions. I believe that in order to shift outcomes, we must provide an immediate neuropsychological and educational evaluation, then engage every child in intensive, appropriate, trauma-informed therapies from the time of entry into care.

Click here for more from the May issue of Contemporary Pediatrics.


1. Haskins RJK. Keeping up with the caseload: How to recruit and retain foster parents. Brookings. Published March 9, 2022.

2. Strolin JS, McCarthy M, Caringi J. Causes and Effects of Child Welfare Workforce Turnover. Journal of Public Child Welfare. 2006;1(2):29-52. doi:10.1300/j479v01n02_03

3. About Child Trauma. The National Child Traumatic Stress Network. Published November 5, 2018.

4. Clark SL, Palmer AN, Akin BA, Dunkerley S, Brook J. Investigating the relationship between trauma symptoms and placement instability. Child Abuse & Neglect. 2020;108. doi:10.1016/j.chiabu.2020.104660

5. Greenwald. Child Report of Post-traumatic Symptoms. The National Child Traumatic Stress Network. Published December 1, 2017. Accessed September 19, 2021.

6. Morton. The Power of Community: How Foster Parents, Teachers, and Community Members Support Academic Achievement for Foster Youth. Journal of Research in Childhood Education. 2015;30(1):99-112. doi:10.1080/02568543.2015.1105334

7. Summersett FC, Jordan N, Griffin G, Kisiel C, Goldenthal H, Martinovich Z. An examination of youth protective factors and caregiver parenting skills at entry into the child welfare system and their association with justice system involvement. Children and Youth Services Review. 2019;99:23-35. doi:10.1016/j.childyouth.2019.01.001

8. Courtney, Dworsky, Brown, Cary, Love, Vorhies. Midwest Evaluation of the Adult Functioning of Former Foster Youth: Outcomes at Age 26. Chapin Hall at the University of Chicago; 2011.

9. Putnam-Hornstein, Lery, Hoonhout, Curry. A Retrospective Examination of Child Protection Involvement Among Young Adults Accessing Homelessness Services. American Journal of Community Psychology. 2017;60(1-2):44-54. doi:10.1002/ajcp.12172

10. Cancel S, Fathallah S, Nitze M, Sullivan S, Wright-Moore E. Aged Out: How We’re Failing Youth Transitioning Out of Foster Care. Think Of Us; 2022.

11. Pettersson E, Lichtenstein P, Larsson H, et al. Genetic influences on eight psychiatric disorders based on family data of 4 408 646 full and half-siblings, and genetic data of 333 748 cases and controls. Psychological Medicine. 2018;49(07):1166-1173. doi:10.1017/s0033291718002039

12. Hutchison, E. D. (2019). Human Behavior in the Social Environment: Conception through Middle Childhood: Vol. Custom (1st ed.) [EPub].

13. Choi YJ, Choi EJ, Ko EJ. Neurofeedback Effect on Symptoms of Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis. Applied Psychophysiology and Biofeedback. 2023;48(3):259-274. doi:10.1007/s10484-023-09593-3

14. Umaç EH, Semerci R. Effect of Biofeedback-Based Interventions on the psychological Outcomes of Pediatric Populations: A systematic review and Meta-analysis. Applied Psychophysiology and Biofeedback. 2023;48(3):299-310. doi:10.1007/s10484-023-09583-5

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