AAP Voices Blog

Fostering a Better Type of Care

Most of us have had a moment in our lifetime that offers the possibility of changing our course. The thought usually fades as suddenly as it happens, leaving it as just a possibility. For others though it has an indelible impact that leads to change. I am in that second group. 

I will never forget the expression on my 16-year-old patient’s face when he asked me, “What did I do at six months old to be placed in foster care?” I was a second-year resident on the path to becoming a pediatric endocrinologist. He was brand new to me. Despite my overwhelming sense of inadequacy in the moment, I somehow gathered my wits long enough to respond, “You couldn’t have done anything. You were just a baby. But I’m going to find out the answer.” And so began my exploration of the foster care system in all its complexity.

Today I am credited with leading the creation of the first national guidelines for the health care of children and teens in foster care. I credit that teenage patient for asking me a question that led to deep reflection, changing my entire career trajectory. My mission since has been to improve the quality of the life and health outcomes for our children and youth who spend time in foster or kinship care, or who are at risk of placement away from their families.

As we celebrate National Foster Care Awareness Month, I want to spotlight the American Academy of Pediatrics and the work it has been doing to improve foster care outcomes. In particular, I recognize the AAP’s recent completion of a crucial assessment of the early implementation of the congregate care provisions under the Family First Prevention Services Act. I encourage everyone to read the new report, Family First Implementation: A One-Year Review of State Progress in Reforming Congregate Care. 

Family First, which became law in 2018, was designed to reform child welfare policies and practice in two major ways. First, Family First allows states to use Title IV-E funds to support evidence-informed and promising services for families and children that have been shown to reduce the need for foster care. The second set of reforms are the new quality and adequacy standards for non-family settings (often referred to as “congregate” or “group” care) that also promote family-based placements. What we know from the latest AAP study is that, despite early state progress in implementing these policies, significant opportunities remain to transform the vision of Family First into a reality for young people in foster care. 

“The bottom line is that every child and teen deserve to have suitable care – care that is family-based whenever possible, physically and emotionally safe, developmentally and trauma-informed, and nurturing of their well-being.”

The 1909 White House Conference on Children declared that “Children fare best in families.” The goal of Family First is two-fold: to reduce the number of children and teens in out-of-home care and to identify a suitable family setting for those children who are in out-of-home care so that only those truly in need of high quality therapeutic congregate care receive it. Congregate care is not suitable for the vast majority of children and teens in care. To achieve these goals, we must call on lawmakers to act. Of the eight policy recommendations included in the new report, two stand out: 1) Professionalize and invest in Qualified Residential Treatment Program (QRTP) staff to ensure high-quality, individualized treatment when youth need such care and, 2) Establish performance- and outcome-based monitoring of QRTPs. 

Some of you may have heard about the story of Cornelius Fredericks – a 16-year-old Black youth in foster care who died during a physical restraint by the staff of a Michigan group home in May 2020. His death focused much-needed attention on the use of institutional placements in foster care. The research and design lab, Think of Us, conducted a nationwide case-study after this tragic event and found that institutional placements: 

• Failed to meet the child welfare mandates of safety, permanency, and well-being
• Were prison-like and punitive
• Were traumatic and unfit for healthy child and adolescent development
• Shielded youth from building relationships that would get them out of institutions
• Were environments in which youth feel like they did not have a way out

The bottom line is that every child and teen deserve to have suitable care – care that is family-based whenever possible, physically and emotionally safe, developmentally and trauma-informed, and nurturing of their well-being. Care should also favor permanency in a forever home through reunification, guardianship, or adoption. This means engaging families, extended families and nonrelative foster caregivers. Since the quality of care is always only as good as the people providing it, we need people who have a genuine heart for children, whether family caregivers or supervisors and staff in a group setting.

I am encouraged by the many opportunities to better support child welfare professionals, care providers and young people in the child welfare system as Congress looks to reauthorize Title IV-B of the Social Security Act later this year. Hopefully, bipartisan efforts will consider the multiple opportunities for addressing the training and education needs of leadership, staff, and caregivers so they can in turn provide the best care for and promote the well-being of traumatized children and youth. This is central to and necessary for high-quality family-based care and congregate care reform.

As I reflect on my own personal journey during this National Foster Care Month, I have learned so many valuable lessons from my patients, their caregivers, and my child welfare colleagues. My hope is that communities everywhere will accept and embrace the children and families who are relying on them. We are all creating the future together for our children, and we all have a role to play in ensuring that every child is nurtured, loved and cared for. Whether you speak up for one child or many, doing so can change your life.