Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Epidemiology of foster care placement and overview of the foster care system in the United States

Moira A Szilagyi, MD, PhD
Sandra H Jee, MD, MPH
Section Editors
Marilyn Augustyn, MD
Jan E Drutz, MD
Deputy Editor
Mary M Torchia, MD


Children and adolescents who spend time in foster care have been exposed to multiple adverse childhood experiences and trauma. This is also true for other children whose families are involved with the child welfare system and children living away from their parents in informal placements with relatives.

An understanding of the structure, goals, and mandates of the foster care system, as well as the unique health, mental health, developmental, and educational problems of children and adolescents in foster care facilitates provision of appropriate comprehensive care to this vulnerable population [1,2]. In particular, health providers need to consider and be able to educate other professionals and caregivers about the impact of early childhood adversity and trauma on emotional, behavioral, and developmental health. (See "Comprehensive health care for children in foster care", section on 'Complex childhood trauma and toxic stress'.)

The epidemiology of foster care placement and an overview of the structure, goals, and mandates of the foster care system will be discussed here. The health, mental health, developmental, and educational needs of children in the foster care system are discussed separately. (See "Comprehensive health care for children in foster care".)


Children and adolescents are placed in foster care when their parents are unwilling or unable to safely care for them [1,3]. Children and adolescents who are placed in foster care have suffered childhood trauma or a variety of adverse childhood experiences. Placement in foster care is intended to be a temporary arrangement during which the health and safety of children are protected while the birth parents are provided with services that support reunification with their children.

Foster care is mandated to seek timely permanency for children in its care, either through reunification with family, placement with relatives, or adoption. If independent living is a realistic goal for an adolescent, foster care is mandated to provide services that nurture the adolescent toward independent adult living.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Apr 7, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Szilagyi M. The pediatric role in the care of children in foster and kinship care. Pediatr Rev 2012; 33:496.
  2. Mather M. Adoption: a forgotten paediatric speciality. Arch Dis Child 1999; 81:492.
  3. Jee SH, Simms MD. Health and well-being of children in foster care placement. Pediatr Rev 2006; 27:34.
  4. US Department of Health and Human Services. Administration on Children, Youth and Families, Children's Bureau. The AFCARS Report. www.acf.hhs.gov/sites/default/files/cb/afcarsreport22.pdf (Accessed on October 22, 2015).
  5. Wildeman C, Emanuel N. Cumulative risks of foster care placement by age 18 for U.S. children, 2000-2011. PLoS One 2014; 9:e92785.
  6. Conn AM, Szilagyi MA, Franke TM, et al. Trends in child protection and out-of-home care. Pediatrics 2013; 132:712.
  7. Administration for Children, Youth and Families. Office of Data, Analysis, Research and Evaluation. Recent Demographic Trends in Foster Care. www.acf.hhs.gov/sites/default/files/cb/data_brief_foster_care_trends1.pdf (Accessed on October 20, 2015).
  8. Rosenfeld AA, Pilowsky DJ, Fine P, et al. Foster care: an update. J Am Acad Child Adolesc Psychiatry 1997; 36:448.
  9. Simms MD. Medical care of children who are homeless or in foster care. Curr Opin Pediatr 1998; 10:486.
  10. Schor EL. Foster care. Pediatr Rev 1989; 10:209.
  11. US Department of Health and Human Services, Administration for Children, Youth and Families. Child maltreatment 2012. US Government Printing Office, Washington DC, 2005. Available at: www.acf.hhs.gov/sites/default/files/cb/cm2012.pdf (Accessed on April 28, 2014).
  12. COUNCIL ON FOSTER CARE, ADOPTION, AND KINSHIP CARE, COMMITTEE ON ADOLESCENCE, and COUNCIL ON EARLY CHILDHOOD. Health Care Issues for Children and Adolescents in Foster Care and Kinship Care. Pediatrics 2015; 136:e1131.
  13. US Department of Health & Human Services. Child Maltreatment 2010. www.acf.hhs.gov/programs/cb/pubs/cm10/cm10.pdf (Accessed on January 25, 2012).
  14. Child welfare and juvenile justice: Federal agencies could play a stronger role in helping states reduce the number of children placed solely to obtain mental health services. GAO-03-397, United States General Accounting Office, Washington, DC 2003.
  15. Simms MD. Foster children and the foster care system, Part II: Impact on the child. Curr Probl Pediatr 1991; 21:345.
  16. National Commission of Family Foster Care. A Blueprint for Fostering Infants, Children, and Youths in the 1990s, Child Welfare League of America, Washington, DC 1991.
  17. Szilagyi MA, Jee SH, Toth S, et al. Outpatient specialty mental health utilization for children in foster care. Pediatric Academic Societies' Meeting, San Francisco, CA, 2006.
  18. Lindsey D. Factors affecting the foster care placement decision: an analysis of national survey data. Am J Orthopsychiatry 1991; 61:272.
  19. Pecora PJ, Kessler RC, Williams J, et al. Improving family foster care. Findings from the Northwest foster care alumni study. www.casey.org/Resources/Publications/ImprovingFamilyFosterCare.htm (Accessed on January 25, 2012).
  20. James S, Landsverk J, Slymen DJ. Placement movement in out-of-home care: Patterns and predictors. Child Youth Serv Rev 2004; 26:185.
  21. Rubin DM, Downes KJ, O'Reilly AL, et al. Impact of kinship care on behavioral well-being for children in out-of-home care. Arch Pediatr Adolesc Med 2008; 162:550.
  22. Child Welfare League of America. Standards for Foster Family Service. Child Welfare League of America, New York 1975.
  23. Fein E. The elusive search for certainty in child welfare: introduction. Am J Orthopsychiatry 1991; 61:576.
  24. Shyne AW, Schroeder AG. National study of social services to children and their families: Overview. Bulletin 017-091-0025-8. US Government Printing Office, Washington, DC 1978.
  25. P.L. 96-272, Approved June 17, 1980 (94 Stat.500) Adoption Assistance and Child Welfare Act of 1980. www.ssa.gov/OP_Home/comp2/F096-272.html (Accessed on January 25, 2012).
  26. Public Law 105-89. Adoption and Safe Families Act of 1997 www.acf.hhs.gov/programs/cb/laws_policies/cblaws/public_law/pl105_89/pl105_89.htm (Accessed on January 25, 2012).
  27. US Department of Health and Human Services. Administration for Children and Families. Fostering Connections to Success and Increasing Adoptions Act of 2008, P.L. 110-351. Available at: www.childwelfare.gov/systemwide/laws_policies/federal/index.cfm?event=federallegislation.viewlegis&id=121 (Accessed on April 28, 2014).
  28. US Department of Health and Human Services Administration for Children and Families. Report to the congress on kinship foster care. June 2000. aspe.hhs.gov/HSP/kinr2c00/ (Accessed on January 25, 2012).
  29. Sakai C, Lin H, Flores G. Health outcomes and family services in kinship care: analysis of a national sample of children in the child welfare system. Arch Pediatr Adolesc Med 2011; 165:159.
  30. Stein RE, Hurlburt MS, Heneghan AM, et al. Health status and type of out-of-home placement: informal kinship care in an investigated sample. Acad Pediatr 2014; 14:559.
  31. Winokur M, Holtan A, Valentine D. Kinship care for the safety, permanency, and well-being of children removed from the home for maltreatment. Cochrane Database Syst Rev 2009; :CD006546.
  32. Foster care: health needs of many young children are unknown and unmet. GAO/HEHS-95-114, US General Accounting Office, Washington, DC 1995.
  33. American Academy of Pediatrics. Committee on Early Childhood and Adoption and Dependent Care. Developmental issues for young children in foster care. Pediatrics 2000; 106:1145.
  34. Dozier M, Albus K, Fisher PA, Sepulveda S. Interventions for foster parents: implications for developmental theory. Dev Psychopathol 2002; 14:843.
  35. Fisher PA, Burraston B, Pears K. The early intervention foster care program: permanent placement outcomes from a randomized trial. Child Maltreat 2005; 10:61.
  36. Reddy LA, Pfeiffer SI. Effectiveness of treatment foster care with children and adolescents: a review of outcome studies. J Am Acad Child Adolesc Psychiatry 1997; 36:581.
  37. Goldman, J, Salus, MK, Wolcott, D, Kennedy, KY. A coordinated response to child abuse and neglect: The foundation for practice. Chapter Five: What factors contribute to child abuse and neglect? www.childwelfare.gov/pubs/usermanuals/foundation/foundatione.cfm (Accessed on January 25, 2012).
  38. Fanshel D, Shinn EB. Children in Foster Care: A Longitudinal Investigation, Columbia University Press, New York 1978.
  39. Gean MP, Gillmore JL, Dowler JK. Infants and toddlers in supervised custody: a pilot study of visitation. J Am Acad Child Psychiatry 1985; 24:608.
  40. American Public Human Services Association. Medicaid access to youth aging out of foster care. www.aphsa.org/Home/Doc/Medicaid-Access-for-Youth-Aging-Out-of-Foster-Care-Rpt.pdf (Accessed on January 25, 2012).
  41. Putnam-Hornstein E, Hammond I, Eastman AL, et al. Extended Foster Care for Transition-Age Youth: An Opportunity for Pregnancy Prevention and Parenting Support. J Adolesc Health 2016; 58:485.
  42. Webinar: The Health of Children in Foster Care: Making Improvements Through Medicaid and the Law, Archived at National Institute for Health Care Management Foundation, broadcast on April 16, 2013. www.nihcm.org (Accessed on April 24, 2013).
  43. Taussig HN, Clyman RB, Landsverk J. Children who return home from foster care: a 6-year prospective study of behavioral health outcomes in adolescence. Pediatrics 2001; 108:E10.
  44. Courtney M, Terao S, Bost N. Midwest evaluation of the adult functioning of former foster youth: conditions of youth preparing to leave state care. Chapin Hall Center for Children, Chicago, IL 2004.
  45. Courtney ME, Dworsky A, Hook J, et al. Midwest evaluation of the adult functioning of former foster youth. www.chapinhall.org/research/report/midwest-evaluation-adult-functioning-former-foster-youth (Accessed on January 25, 2012).
  46. Dworsky A, Napolitano L, Courtney M. Homelessness during the transition from foster care to adulthood. Am J Public Health 2013; 103 Suppl 2:S318.
  47. Ahrens KR, Garrison MM, Courtney ME. Health outcomes in young adults from foster care and economically diverse backgrounds. Pediatrics 2014; 134:1067.