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Psychological Adjustment of Children in Foster Care: Review and

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DOI: 10.1080/15548732.2011.617272

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 Journal of Public Child Welfare, Vol. 6:129–148, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 1554-8732 print/1554-8740 online
DOI: 10.1080/15548732.2011.617272

Psychological Adjustment of Children in

Foster Care: Review and Implications
for Best Practice

ANDREA M. JONES and TRACY L. MORRIS

Downloaded by [West Virginia University], [Tracy L. Morris] at 09:23 07 May 2012

West Virginia University, Morgantown, WV, USA

Approximately 800,000 children are served by the foster care and

adoption system each year based on 2008 data from the United
States Department of Health and Human Services. While receiving
services, children in the system often undergo multiple placements,
in addition to having endured traumatic experiences such as
child maltreatment and neglect. These experiences make foster
care children more likely to experience adjustment and behavior
problems. With such a large number of children in the foster care
and adoption system, it is important to understand protective and
risk factors playing a part in their ability to be resilient as well
as barriers to treatment that may affect optimal adjustment. The
current review examines adjustment difficulties as well as risk and
protective factors, barriers to mental health care, and discusses
clinical implications.

KEYWORDS foster children, adjustment, resiliency

Each year approximately 800,000 children are served by the foster care and
adoption system, including, but not limited to, children who are waiting
to be adopted, children whose parents’ rights have been terminated, and
children who have been adopted (U.S. Department of Health and Human
Services [US DHHS], 2008). At the end of the 2007 fiscal year, the Adoption
and Foster Care Analysis and Reporting System (AFCARS; U.S. Department of
Health and Human Services, 2009) reported 783,000 children were served in
the fiscal year of 2007. With such high rates of children being served through

Received: 06/09/09; revised: 02/11/11; accepted: 02/11/11

Address correspondence to Tracy L. Morris, West Virginia University, Department of
Psychology, 1124 Life Sciences Building, 53 Campus Drive, Morgantown, WV 26506-6040,
USA. E-mail: [email protected]

129
 130 A. M. Jones and T. L. Morris

the adoption and foster care system each year, it is important to examine
how children in the system adjust to such life changes. For the purposes
of this review, adjustment will be defined as the lack of behavioral and
emotional problems and the presence of adaptive functioning. Adjustment
is especially considered in the context of how states are evaluated regarding
their ability to uphold the child welfare outcomes as laid out by the Adop-
tion and Safe Families Act (ASFA) of 1997 (Public Law 105-89). Expected
outcomes include: keeping children safe (e.g., reducing the recurrence of
child abuse and neglect and the incidence of child abuse and/or neglect in
foster care), achieving permanency for children in foster care (e.g., increasing
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permanency, reducing time in foster care without increasing reentry, and

reducing time in foster care to adoption), and achieving stable and age-
appropriate placements (e.g., increasing placement stability and reducing
placements of young children in group homes or institutions) (USDHHS,
2002).
The purpose of the review is to discuss adjustment difficulties experi-
enced by foster care children, policy leading to barriers in treatment, and
problems associated with aging out of foster care. Finally, implications for
policy and clinical directions are elucidated. Articles included in the review
were collected using the EBSCO Host search engine and were selected based
on their discussion of variables affecting optimal adjustment of foster care
children and discussion of best practice.

ADJUSTMENT DIFFICULTIES

One way children are introduced to the adoption and foster care system is
through the experience of abuse or neglect. Adjustment difficulties incurred
by children who have survived neglect or abuse include academic, social,
behavioral, and psychological problems. Heflinger, Simpkins, and Combs-
Orne (2000) examined 254 children (ages 4–18 years), who were wards of the
state of Tennessee during January of 1996. Caretakers of the children were
charged to complete the Child Behavior Checklist (CBCL), which assesses
clinical elevations of children. Review of the completed CBCLs revealed that
34% of the foster children included in the sample had clinically significant el-
evations on the following subscales: aggressive, delinquent, destructive, and
withdrawn. These subscales fall within two scales that comprise the CBCL—
the Internalizing and Externalizing Problem Scales. Overall 19% of the sample
had clinically significant elevations on the Internalization Scale, while 23%
had clinically significant elevations on the Externalization Scale. Based on
the cutoff scores set by Achenbach and Edelbrock (1981) for the CBCL, only
approximately 10% of the nonclinically referred sample would qualify for a
disorder at the clinical level. These findings indicate that children in the foster
care system are at increased risk for clinically significant behavior problems.
 Adjustment in Foster Care Children 131

Although the ASFA of 1997 (Public Law 105-89) has as its goal to limit
the number of children in the foster care system and to promote family
reunification, return to the foster care system may be due to the increase in
family dysfunction and heightened familial stress including family conflict,
deviant parental behavior, and the presence of violence once the child is
returned to his/her biological parents (Lau, Litrownik, Newton, & Landsverk,
2003). Additionally, research has shown that reentry into the foster care
system following reunification with one’s biological parents is associated with
higher CBCL scores (Barth, Weignesberg, Gisher, Fetrow, & Green, 2008).
Of concern is that those who are reunified with their biological parents
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are also less likely to utilize mental health services and are more likely to
experience more adverse life events (Lau et al., 2003). Type of foster care
also seems to account for problem behavior in foster children as Marinkovic
and Backovic (2007) found that children placed in group foster homes scored
higher on all problem scales. They attributed these differences to the fact that
children living in foster families tend to be placed as toddlers and live with
the same foster family for a longer period with fewer placement changes.
Detrimental effects of late placement are apparent in the higher amount of
somatic complaints and internalizing problems experienced by older children
being placed with foster families.
It also appears that certain children are more likely to reenter the foster
care system. Courtney (1995) found that African American children and chil-
dren with health problems, receiving Aid to Dependent Children, spending
3 months or less in care, placed in nonrelative care, and children with
a higher number of placements during their first time in the foster care
system are more likely to reenter foster care. Wells and Guo (1999) also
studied reunification and reentry and found that African American children
reentered foster care 97.9% faster than Caucasian children, children that
were victims of physical abuse reentered 70.9% slower than children placed
due to substance dependency, and that children who were last placed in
a group home reentered the foster care system at a rate of 232% faster
than children whose last placement was with a relative. By contrast, an
increase in the number of months a child spends in a particular placement
is associated with a 5.1% decrease in the annual reentry rate. A later study
by Shaw (2006) corroborated earlier findings by Courtney (1995) and Wells
and Guo (1999) finding that those placed in kinship care have the lowest
rates of reentry and that African American youth and youth in single parent
families are more likely to reenter care. Shaw added to earlier findings
by demonstrating that no gender difference was evident when evaluating
reentry; however, the following groups are more likely to reenter care:
infants, children who have been neglected compared with those having
been physically or sexually abused, children with less than 3 months in
care, those receiving health coverage through Title IV-E, and children with
siblings. Groups identified by Courtney (1995), Shaw (2006), and Wells
 132 A. M. Jones and T. L. Morris

and Guo (1999) may be at even greater risk for emotional and behavior
problems.
In addition to having a higher rate of internalizing and externalizing
behavior problems, children who are in the adoption and foster care system
often experience difficulties with academic performance (Trout, Hagaman,
Casey, Reid, & Epstein, 2008). Stone (2007) cited three factors related to
poorer educational performance among maltreated children: the effect of
maltreatment, exposure to sociodemographic risk such as residential mo-
bility, and the experience of living without one’s biological parents. Fong,
Schwab, and Armour (2006) posited that performance issues may be due
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to a lack of consistency of school activities, as foster children are often

uprooted from their environment. Fong and colleagues interviewed 103
foster parents about the continuity of their foster child’s activities (e.g.,
school, leisure, family, church, social, and therapeutic activities) and found
that foster children engage in fewer activities after placement compared to
their activity level prior to placement with a foster family. When continuity
of school activity was examined against child well-being, Fong and col-
leagues found that children whose involvement in school activities remained
the same or increased scored higher in levels of well-being than children
whose involvement decreased. Fong et al. (2006) also found that increased
involvement in school activities was associated with an increase in school
grades. Continuity was associated with an improvement of school grades,
while decreased involvement was associated with lower improvement of
school grades. That consistency of prior school related activities affects the
well-being and academic functioning in foster care children is particularly
alarming as foster children are a transient group and often undergo multiple
placements. When examining the effects of multiple placements, Sullivan,
Jones, and Mathiesen (2010) found that the foster children in their study av-
eraged seven placement changes and eight school transfers while in their first
6–7 years in care. Of this sample, 50% of the foster children were performing
below grade level. Additionally, significant correlations were found between
school changes and internalizing and externalizing problems. School changes
during the high school years were particularly detrimental. With regard to
high school completion, Courtney, Piliavin, Grogan-Kaylor, and Nesmith
(2001) found that 37% of foster children had not earned their high school
diploma 12–18 months after having exited foster care compared with a 5%
high school dropout rate in the general population (U.S. Department of
Education [US DOE], 2001).
As most children face multiple placements, it is important to also look
at how stress affects childhood adjustment. While research conducted by
Compas, Howell, Phares, Williams, and Giunta (1989) drew from a normative
sample of children, their findings can be applied to children involved in the
foster care system. Results indicated that stressful life events and psycho-
logical symptoms in both the child and the parent were associated with in-
 Adjustment in Foster Care Children 133

creases in adolescent emotional/behavioral problems, even after controlling

for previous emotional/behavioral problems. As foster care youth often face
tremendous life stressors due to multiple placements, abuse, and/or neglect,
these findings would be expected to hold true for foster children as well.
Building on work indicating that foster children are more likely to
experience heightened internalizing and externalizing behavior problems
and to be affected by inconsistency in their involvement with activities,
Taussig (2002) examined four domains of risk behavior earlier identified
by Widom (1994) including sexual, delinquent/violent, substance use, and
suicidal/self-destructive behaviors. Data were collected for 110 participants
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(age 7–12 years). Participants and their caregivers were interviewed 6 months
after the youth had been placed in the caregivers’ care. Youth were then
interviewed 5 years after the initial interview as to their involvement in
each of the four domains of risk behavior. It should be noted that study
participants were newly referred to the welfare system such that they had
not experienced multiple placements prior to their involvement in the study.
All participants had experienced some form of maltreatment (58.2% neglect,
41.8% caretaker absence, 22.7% physical abuse, 16.4% sexual abuse, and
10.9% other types of maltreatment including emotional abuse). Regression
analyses revealed that control variables (e.g., age gender ethnicity, type of
abuse or maltreatment, total number of behavior problems, cognitive func-
tioning, and adaptive behavioral functioning) and predictor variables (e.g.,
social support, self-perception) accounted for 33% to 46% of the variance in
involvement with risk behaviors at the 5-year follow-up with the predictor
variables accounting for 12% to 19% of the overall variance. Taussig’s study
adds to the current knowledge of adjustment difficulties experienced by
foster care children, as it demonstrates that personal variables affect foster
children’s adjustment outcomes as well.
Work examining social skills has shown that adjustment difficulties in
foster children are not limited to behavioral and academic difficulties. In
fact, several specific domains of peer deficits have been identified including
having fewer friends and possessing significantly younger friends, having
relationships containing higher levels of conflict and lower levels of in-
timacy, more negative peer nominations than positive nominations, and
possessing disruptive social patterns that develop the formation of peer
relationships (see Leve, Fisher, & DeGarmo, 2007 for a review). Work by
Leve and colleagues confirmed past research demonstrating that children in
foster care have worse peer relations than nonfoster children (e.g., Cicchetti
& Lynch, 1995; Parker & Herrera, 1996; Salzinger, Feldman, Hammer, &
Rosario, 1993; see Leve et al., 2007 for a review) but also identified several
gender differences in social skills. For girls, Leve and colleagues found
that factors of the foster care experience account for social isolation and
poorer peer relations than maltreated community girls even when controlling
for a history of disruptive behavior. However, after examining patterns of
 134 A. M. Jones and T. L. Morris

disruptive behavior, foster care girls had more disruptive behavior problems
than community girls. In contrast to the result found for foster care girls,
foster care status was not significantly related to foster care boys disruptive
behavior or peer relations. Leve and colleagues offered that the betrayal of
trust associated with sexual abuse could be affecting female foster children’s
ability to develop meaningful peer relationships. Gender differences also may
be explained by the tendency for girls to be more interested in emotional
aspects and therefore have fewer friends, while boys have a greater tendency
to be more interested in the sharing of similar activities (Rose, 2002). This is
a dynamic that should be explored as foster children increase in age.
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PREDICTIVE FACTORS OF
PSYCHOLOGICAL RESILIENCE

Substantial research (e.g., Compas et al., 1989; Fong et al., 2006; Heflinger
et al., 2000; Taussig, 2002; Trout et al., 2008) has shown that children in the
foster care system endure adjustment difficulties; however, research also has
demonstrated several factors that can lead to psychological resilience in foster
children. In fact, five domains of resilience criteria have been identified:

 Scholastic participation or employability;

 Positive relationships with peers, including having a group of socially
acceptable friends, being capable of romantic relationships, and feeling
accepted and appreciated by peers;
 Being capable of establishing significant, positive relationships with adults;
 Possessing personal characteristics such as setting positive goals, recog-
nizing personal strengths, and respecting oneself; and
 Engaging in behaviors outside foster care placement such as participation
in sports, cultural and other activities (Drapeau et al., 2007).

Drapeau and colleagues also identified three turning points toward resilience
that include action (e.g., getting a job), developing a relationship with an
adult (e.g., developing a significant relationship with a special education
teacher), and reflection.
Legault, Anawati, and Flynn (2006) examined 220 foster children age
14 to 17 years as part of the 3-year, longitudinal study called the Looking
After Children Initiative. Results indicated that foster children are at less
risk for physical aggression if the child has fewer primary caregivers, if
the quality of the relationship with the female caregiver and the foster
child’s friends is high, if the child has high self-esteem, and if the use
of avoidant coping strategies is low. These results suggest that perhaps
foster children’s relationship with others, coping strategies, and self-esteem
could be targeted in order to reduce the chance that the child will engage
 Adjustment in Foster Care Children 135

in later physical aggression. Oosterman and Schuengel (2008) add to the

understanding of the importance of the relationship between foster child
and caregiver through their finding that parental sensitivity, as measured
by observation of a caregiver-child interaction, is positively associated with
attachment security after controlling for symptoms of disordered attachment.
Additionally, they found that secure attachment was negatively associated
with teacher reports of externalizing behavior problems. Strijker and Knorth
(2009) later found that attachment disorders and multiple placements affect
how well the child is able to adjust to their foster family. Results from
Oosterman and Schuengel (2008) and Strijker and Knorth (2009) support
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programs targeting the attachment relationship to affect change in behavior

and adjustment within the foster family.
Earlier work by Marcus (1991) supports the aforementioned studies
finding that there is a positive association between attachment and affection
and child adjustment. Marcus adds to the literature by examining the associ-
ation between attachment and school achievement. Data indicate that school
achievement is associated with attachment to the caregiver such that higher
levels of school achievement problems were associated with an insecure
attachment to the caregiver. Data regarding the length of time a child has
been in foster care and number of foster placements also was collected
and revealed that number of placements was negatively associated with
secure attachment to the caregiver, while the amount of time spent in a
given placement was positively related to secure attachment. These findings
were corroborated by Marinkovic and Backovic (2007), who also found that
children who are removed from the care of their biological families at an
earlier age and who receive stable placements have a greater chance of
developing secure attachments to their caregivers. Results from Rushton,
Mayes, Dance, and Quinton (2003) offer hope for later placed children (ages
5 to 9 years) placed in stable foster homes, as 73% of the children in their
sample were able to developed an attachment to one or both of the foster
parents. Additionally, it does not appear that placing children with relatives
offers a better chance for attachment; rather the number of placements a child
experiences seems to be related to the attachment relationship (Oosterman,
Schuengel, Slot, Bullens, & Doreleijers, 2007).
Linares, Li, Shrout, Brody, and Pettit (2007) found that not only is the
foster child’s relationship with their caregivers important, but sibling unity
during family transitions is also a protective factor against child behavior
problems. Closer examination of the findings reveals that siblings who get
along better (e.g., have more positive relationships as indicated by the Sibling
Relationship Questionnaire assessing affection, companionship, nurturance
of sibling, and nurturance by sibling) have less frequent behavior problems
at follow-up, approximately 14 months after initial evaluation. Siblings with
more negative relationships (e.g., antagonism, competition, and quarreling)
were found to have more frequent behavior problems at the follow-up
 136 A. M. Jones and T. L. Morris

evaluation. Additionally, Linares and colleagues found that placing siblings

together is only beneficial in cases of less frequent behavior problems at
the initial evaluation. Finally, Linares and colleagues found that siblings who
have high levels of behavior problems actually fare better and have less
frequent behavior problems at follow-up if they are separated. No placement
group effect was found, meaning no behavior differences were observed in
disrupted placement versus placement continuously together or placement
continuously apart versus continuously together. Tarren-Sweeney and Hazell
(2005) add to our understanding of the benefits of sibling co-residency by
examining gender differences. In their study examining the mental health of
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347 children placed in foster care, Tarren-Sweeney and Hazell found that
girls separated from their siblings were at greater risk for poorer mental
health (as measured by the CBCL) and socialization (as measured by CBCL
social competence scores) than girls who resided with at least one sibling.

POLICY LEADING TO BARRIERS IN TREATMENT

While children in the foster care system may incur any one or several of the
aforementioned adjustment difficulties, policy and the child’s living situation
may create challenges in the delivery, coordination, and continuity of care
(Simms, Dubowitz, & Szilagyi, 2000). In fact, mental health agencies report
the following barriers to the delivery of mental health services: frequency of
change of placement (noted by 83.8% of surveyed mental health agencies
as a problem), underreporting of mental health problems by foster parents
(43.2%), underreporting of mental health problems by social workers (37.8%
of state mental health facilities and 49.9% of county mental health agencies),
and underreporting of mental health problems by physicians (45.9% of state
mental health agencies and 40.6% of county mental health agencies [Ragha-
van, Inkelas, Franke, & Halfon, 2007]). The authors further noted that rather
than drawing from Medicaid funds that cover basic mental health services,
services are being delayed as mental health agencies often are drawing from
Title IV and other state funds to deliver mental health services.
Several problems with the administration of Medicaid also may con-
tribute to its limited use (Kerker & Doore, 2006). For example, Kerker and
Doore state that Medicaid provides only ‘‘modest provider reimbursements’’
(p. 140) that reduce the chance that providers will accept Medicaid as a form
of payment. When providers do accept Medicaid, the number of reimbursed
sessions that can be used to treat foster children’s complex needs is restricted
(Simms et al., 2000). Mental health services for foster children are provided
for under parts B and C of the Individuals with Disabilities Education Act
(IDEA); however, funding sources require that foster children served have
serious emotional dysfunction, which means that eligibility for such services
can shift creating inconsistencies in care. Further, when requesting funding,
 Adjustment in Foster Care Children 137

state and local interpretations of federal funding requirements often differ

leading to decreased access to services. Finally, school systems create barriers
to mental health and additional services, as school districts that are under
financial hardship often will not provide psychological assessments and
individualized education plans to foster children who may not be enrolled in
the same school for a full academic year or whose biological family resides
outside of the school district. In such cases, the child’s home school district
is required to pay for such testing; however, such requests are often met
with opposition that foster parents and social workers lack the expertise or
time to advocate for benefits. Without these assessments and/or individual
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education plan, children are not eligible to receive services from their school.
In addition to problems with Medicaid and school systems, Kerker and
Doore (2006) state that child welfare agencies typically do not adequately
screen foster children for mental health problems. When screening does
occur, providers often do not agree as to what constitutes a full psychiatric
evaluation and are not well trained in providing care or evaluating abuse and
neglect that is often incurred by foster care children. In addition, instruments
used by health care providers are not normed on foster care children.

PROBLEMS ASSOCIATED WITH AGING OUT OF

FOSTER CARE

While juveniles often find it difficult to obtain necessary services as foster

children, they are also not afforded much support after aging out of foster
care. As wards of the state, children in the foster care system enter into a
parent–child relationship with the state. Courtney (2009) refers to this rela-
tionship as a corporate parenting relationship that charges the government
to assume the same responsibilities that a biological parent assumes for a
child in their care. Interestingly, this corporate parenting relationship ends
promptly at age 18 years, while youth who are not a part of the foster care
system often do not fully transition out of the care of their biological parents
until their mid to late 20s extending the length of time they require support
from their parents. Courtney further stated that in 2001, 63% of young men
ages 18–24 years and 51% of women ages 18–24 years continued to live with
one or both of their parents. As children age out of the foster care system,
they age out of mandated support from their foster family in addition to
health insurance—including mental health coverage, an area of high need.
Prior work by Courtney and colleagues (e.g., Courtney et al., 2001; Courtney
& Hughes-Heuring, 2005) has shown a correlation between exiting foster
care, loss of health insurance, and a reduction in seeking out health and
mental health services.
Focus groups examining youth who have aged out of the foster care
system have found several common themes. Problems indicated with a
 138 A. M. Jones and T. L. Morris

transition out of the foster care system include a lack of communication

between the foster parent, caseworker, and foster child. Lack of commu-
nication results in the foster child not being included in decision making
and lacking permanent connections and relationships that would give the
child more opportunities for skill building activities needed to be success-
ful after leaving the system. Such activities include opportunities to assist
with paying bills, learning information regarding services that government
agencies provide, and life skills needed to live on one’s own (Scannapieco,
Connel-Carrick, & Painter, 2007). In a separate survey of focus groups,
Geenen and Powers (2007) found that foster children have little opportu-
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nity to develop skills in self-determination needed to survive on their own

while in foster care. Foster children state that their opinion and input is
often disregarded by their foster parents and social workers and that the
opportunity to make their own decisions and learn from their mistakes
while in foster care would have been useful. Foster youth also expressed
that there is little collaboration between agencies, which leads to confusion
of roles, gaps in services, and duplication of services. Lack of collabora-
tion was identified as a problem both while in foster care and after aging
out of care. The importance of relationships also emerged as a common
theme among foster youth. Youth identified the development of meaning-
ful relationships as being one way that they could maintain support and
information resources as they age out of foster care. These relationships
could extend from caseworkers to foster families. Finally, foster care children
with some sort of disability find additional barriers in that youth, who have
a mild disability, may be considered as functioning too highly to receive
specialized services and are grouped with foster youth who do not have a
disability.
Goerge, Lee, Needell, Brookhart, and Jackman (2002) found that once
foster children age out of foster care, the majority are unemployed with only
45% earning a salary. The majority of those who are employed have earnings
below the poverty level and progress more slowing through the job market
than other youth. Courtney (2009) attributes this disparity in the job market to
education. For example, Burley and Halpern (2001) examined foster children
in Washington and found that only 59% of foster children enrolled in eleventh
grade completed high school at the end of twelfth grade, while 86% of non-
foster youth graduated. Similar findings were found for foster care children
in Wisconsin where only 63% of foster care children completed high school
12 to 18 months after aging out of foster care (Courtney et al., 2001). These
trends may begin during the elementary school years, since twice as many
foster care children were found to have repeated a grade, changed schools
during the year, or be enrolled in special education programs as nonfoster
care children (Burley and Halpern). Burley and Halpern also found a 15–
20 percentile point disparity between foster and nonfoster care children on
achievement testing.
 Adjustment in Foster Care Children 139

POLICY AND CLINICAL IMPLICATIONS

With such a large volume of research indicating the adjustment difficulties

for children entering the foster care and adoption system, it becomes in-
creasingly important to assess how these children are handled from their
first contact with a protective service agency (e.g., Child Protective Services,
Child and Youth Services). Having to first discuss one’s abuse, neglect, or
maltreatment with law enforcement, social workers, and an investigative
team often results in retraumatization of the child who is already faced with
the adverse side effects of the initial trauma and the stress incurred with
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life changes as a result of the abuse, neglect, or maltreatment. Mouzakitis

(1985) noted that investigative interviews can be particularly hard for children
because of a high level of emotions present such as anger, denial, and
hostility. Children’s Advocacy Centers (CAC) were created in 1985 to address
the issue of multiple investigative interviews held by law enforcement and
protective service agencies (National Children’s Alliance, 2008). Rather than
holding multiple investigative interviews, CACs provide a nonconfrontational
environment where children are interviewed by a licensed therapist, while
the multidisciplinary team consisting of law enforcement, prosecuting attor-
neys, and the protective service agency observe. Children are thus benefited
in that the person interviewing them is a trained therapist and interviewer
who will conduct a standard interview designed to reduce the likelihood
of future traumatization. CACs also serve the child by providing postinves-
tigative services to the child and family in the form of therapy provided
free of charge and helping to locate resources within the community to
help the child cope with impending life changes and the abuse, neglect,
or maltreatment previously suffered by the child. In addition CACs offer
community-based, educational programs to help prevent future child abuse
or neglect; high-conflict parenting classes; parenting groups for both mothers
and fathers; healthy girls’ and boys’ groups; and family visitation programs.
While CACs offer a wide range of services designed to protect children from
future abuse or neglect and to prevent abuse and neglect, not all counties
and states utilize CACs. Thus, more community programs should be formed
and utilized to immediately help children to begin the adjustment process.
After introduction to the foster care and adoption system, foster children
are matched with a case manager. As such, the role social service agencies
play in achieving optimal adjustment and placement permanency becomes
important when examining clinical and policy outcomes. In a 2005 report,
Flower, McDonald, and Sumski cited case management turnover as a variable
affecting placement permanency and adjustment. From 2003 to 2004, the
turnover rate was 34% to 67% for case management staff within the Bureau
of Milwaukee Child Welfare. This finding contrasts the 10% and less rate for
intake and assessment, private agency adoption, and foster care staff. Such
high rates in case management worker turnover is attributed to low salary in
 140 A. M. Jones and T. L. Morris

comparison to other agency staff, low rates of certification as social workers,

deficiency in ongoing training, and failure to be adequately informed of all
tasks associated with their position as a case manager upon hire. Results from
the Georgia Cold Case Project reflect other agency factors associated with a
lack of placement permanency (Meredith, Speir, Baldwin, Johnson, & Hull,
2010). One agency-related variable affecting permanency is assigning foster
children to alternative living arrangements before reunification, adoption,
legal guardianship, and permanent placement with a relative have been
exhausted. Other problems identified include:
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 Failure to hold a permanency hearing within 1 year of contact with child

welfare;
 Connect the child with an independent living programs (ILP);
 Include the child in permanency planning and transitional living plans;
 Provide the child legal representation during permanency hearings; and
 Failure to make plans for the child’s education, health, and housing needs.

For optimal adjustment, factors such as employee turnover and case man-
agement duties must be assessed to ensure child welfare agencies are not
contributing to problems with placement permanency.
Receiving evidenced-based psychological therapy also is useful in help-
ing children to better adjust after having been abused, neglected, or mal-
treated. Currently, the most commonly used, evidence-based therapy for
abused and neglected children is trauma-focused cognitive behavioral ther-
apy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006). For victims of child
sexual abuse, TF-CBT has been shown to reduce symptoms of anxiety, de-
pression, sexual preoccupation and distress, and dissociation (Cohen, Man-
narino, & Knudsen, 2005). Additionally, TF-CBT has been shown to reduce
symptoms of post-traumatic stress disorder for children who have been
physically, sexually, or emotionally abused (Feather & Ronan, 2006). TF-
CBT will help with emotions and subsequent internalizing and externalizing
behavior experienced due to the abuse, neglect, or maltreatment, but it will
not specifically address issues of attachment and relationship quality with
the new caregiver.
Other research (e.g., Marcus, 1991; Lynskey & Fergusson, 1997; Rushton
et al., 2003; Legault et al., 2006) indicates that the quality of the relationship a
child has with a caregiver is predictive of later adjustment and development
of internalizing and externalizing behavior problems. As such, development
of policy and programs, designed specifically to address how foster parents
and children can forge a more attached, quality relationship with each other,
is needed. Receiving, at the minimum, some form of psychoeducation re-
garding what can be expected over time would be helpful to both foster child
and parent. This education may be especially helpful as unrealistic parental
expectations are associated with insecure parent-child relationships, greater
 Adjustment in Foster Care Children 141

parenting stress, and greater risk of future abuse (Azar & Rohrbeck, 1986;
Budd, Holdsworth, & HoganBruen, 2006). Additionally, Anctil, McCubbin,
O’Brien, and Pecora (2007) found that when ‘‘developmentally appropriate
services’’ (p. 1021) aimed at enhancing protective factors are paired with
unstable foster care placements, multiple placements no longer significantly
predicted adult psychological outcomes.
To address the necessity of the foster child forming a secure attachment
to their foster parent, programs specifically targeting the parenting relation-
ship are required. Parent training programs have been found to increase
the level of attachment a child has to a parent as well as help to reduce
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behavior problems (Chamberlain et al., 2008; Fisher, Gunnar, Chamberland,

& Reid, 2000; Nilsen, 2007). For example, Keeping Foster Parents Trained and
Supported (KEEP), a program based on Multidimensional Treatment Foster
Care (Chamberlain, 2003), offers supportive coaching to foster care parents to
increase their attention to positive behaviors and teaches parents to use ‘‘non-
harsh contingent discipline methods’’ (p. 24) for undesired behaviors. Parents
enrolled in the course were found to have increased parental effectiveness
in positive parenting and the implementation on ‘‘non-harsh contingent dis-
cipline methods’’ (p. 24). The severity of child behavior problems present
also decreased, which was especially true for children entering the foster
care system with higher levels of initial problem behavior (Chamberlain
et al., 2008). Fostering Futures, a modification of Webster-Stratton’s (1981)
Incredible Years, has been used as a preventative intervention for school-
age children in foster care. Results of the program indicate that foster parent
reports of conduct symptoms (e.g., lying, stealing, having problematic peers,
and troublemaking behavior) were significantly lower in the treatment group
than symptoms reported in the nontreatment group. Also a trend was found
for lower externalizing behaviors in the treatment group than in the no-
treatment group. Finally, research examining Early Intervention Foster Care
(EIFC) designed to increase parent utilization of ‘‘consistent, non-abusive
discipline, high levels of positive reinforcement, and close monitoring and
supervision of the child’’ (Fisher et al., 2000, p. 1357) has indicated that
foster parents completing the program ‘‘adopted and maintained’’ (p. 1356)
positive parenting practices taught in the program. Their foster children
show improved behavioral adjustment, as measured by the Early Childhood
Inventory assessing emotional and behavioral disorders. Additionally, foster
children experienced decreases in biological indicators of stress that were
similar to the comparison group of typically developing children (Fisher
et al., 2000).
Research regarding the quality of relationships and child adjustment
is not limited to just the foster child–foster parent relationship, rather it
extends to sibling and peer relationships as well. Work by Linares et al.
(2007) suggests it would be advantageous to work on the quality of sibling
relationships, as positive sibling relationships have been associated with
 142 A. M. Jones and T. L. Morris

fewer behavioral problems while negative sibling relationships have been

associated with greater behavioral problems. In addition, peer relationships
of children in the foster care program should be closely monitored as Lynskey
and Fergusson (1997) found that affiliations with ‘‘delinquent or substance-
using peers’’ (p. 1177) were associated with greater maladjustment. Pro-
grams emphasizing positive relationships between siblings and peers may
prove beneficial; however, these are things that can be addressed in therapy
as well.
While it may be difficult to maintain consistency in the sometimes
transient life of a foster child, Fong et al. (2006) found that consistent school
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activity is imperative for the child’s well-being and continued academic suc-
cess. Availability and location of foster parents may prevent foster children
from engaging in activities at a particular school; however, foster parents,
social workers, and policy makers should strive to make sure that foster
children are given the opportunity to maintain their level of involvement in
school activities if prior activities are available at their new school.
Several studies have examined demographic factors associated with
reentry to the foster care system following familial reunficiation. These stud-
ies have found higher entry rates for infants, those receiving Aid to Depen-
dent Children or health coverage through Title IV-E, and African American
children. Children with siblings, health problems, high numbers of place-
ments during their first time in the foster care system or who spend less
than 3 months in care, and those placed in nonrelative care also have
higher reentry rates (e.g., Courtney, 1995; Shaw, 2006; Wells & Guo, 1999).
Research should be directed toward examining why these groups are more
likely to reenter the system. Both Courtney and Shaw found that children
who spent less than 3 months in care were more likely to reenter the
system following reunification. Policy changes to ensure that caregivers have
been given adequate opportunity to learn new parenting skills and that
the environment provided by the child’s caregiver promotes optimal ad-
justment are needed to reduce multiple placements and poor mental health
outcomes. The need for policy promoting the teaching of parenting skills
also is apparent when reviewing the age group of children most likely to
reenter care. Shaw found that infants are most likely to reenter care, raising
the issue that part of the problem may be that their caregivers are not
ready to be parents. Policy provisions are needed to ensure that parents
are provided sufficient psychoeducation with respect to effective parenting
behaviors across different developmental stages. Placement in kinship care
consistently has been associated with fewer instances of reentry. While kin-
ship care may be an optimal placement strategy, relative caregivers also may
be in need of education and support with respect to child development and
proper parenting practices, particularly when they share the same familial
learning history as the biological parents from whom the children were
removed. Movement is needed away from nonspecific ‘‘parenting’’ classes,
 Adjustment in Foster Care Children 143

toward more individualized services that ensure specific behavioral skills are
generalized to, and maintained in, the home environment. Further, continued
policy efforts are needed to ensure ready access to mental health services
for all those in need.
As aging out of the foster care system often creates difficulties in re-
ceiving adequate information and support needed to survive on one’s own,
educational programming beyond what is provided in primary and sec-
ondary schooling is necessary. Foster children enrolled in ILPs are more
likely to have been taught skills to survive on their own compared to children
not enrolled in the program (Lemon, Hines, & Merdinger, 2005); however,
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experiences in the program have been mixed (Geenen & Powers, 2007).
Some foster children find the classes helpful; however, others feel that the
classes are not sufficient because they do not provide individualized tran-
sition support (Geenen & Powers, 2007). Despite mixed experiences with
ILPs, Geenen and Powers report that those enrolled in the program had
a better educational experience receiving more information about financial
aid, received more college preparatory classes, received more tutoring, and
were younger when they started college for the first time. Additionally, those
enrolled in the program were more likely to receive continued support
and contact with their caseworkers and counselors. Subjects covered in
ILPs include: money management; job readiness and retention skills; how
to obtain housing, health and nutrition; cooking, home maintenance; sex-
ual responsibility; stress management; interpersonal skills; how to complete
college and financial aid applications; financial assistance to foster youth
who have been emancipated to purchase school and work related items;
assistance with housing, food, and transportation, rewards for attending
ILP; computer training; experiential and role-playing activities; workforce
partnerships; SAT preparatory classes; and meetings to discuss resources
available after emancipation (Geenan & Powers, 2007). If successful, the
skills obtained in the ILPs will exponentially increase the skill set of foster
children aging out of the system. As such, policy efforts should be directed
at providing more resources for programs such as ILPs so that foster children
have the necessary resources, knowledge, and skills needed to be successful
after aging out of the foster care system.

CONCLUSION

In conclusion, many policy and clinical implications may be drawn from the
research on children in foster care. Multiple placements and failed attachment
relationships are often associated with behavior and emotional problems. It
is imperative that foster children receive consistent services to address these
issues so that they have the best chance of being able to survive on their
own after aging out of care. Therapists and social workers should monitor
 144 A. M. Jones and T. L. Morris

closely foster children’s relationships not only with their family members but
also their peers. Quality of relationships become increasingly important as
the number of placements the child receives increases. Additionally, while
it may be impossible to maintain all of the foster child’s previous activities,
foster parents should take an active role in ensuring the child’s involvement
in as many prior activities as possible. It is also important for foster parents
to take an even greater interest in their foster child’s friends than do the
parents of nonfoster children because the type of peer affiliations and social
support one has plays an integral role in later child adjustment. Finally,
because aging out of the foster care system often creates a problem for
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foster children in terms of finding the support needed to survive on their

own, programs should be developed that equip foster children with survival
skills and general life knowledge.

Limitations
One obvious limitation in reviewing the effect of foster care on child adjust-
ment is that most studies have been cross-sectional, rather than longitudinal
in nature. With such studies, it is not possible to examine causation. It is
quite possible that children involved with child welfare had behavior and
mental health problems before entering the foster care system. Administering
measures at one time point adds to the difficulty of determining causation
because it is unclear which variable preceded the other. Another limitation
with concern to study methods is that most variables are measured through
self-report questionnaires. Data based on the observation of trained coders
may be more valid in certain contexts. Among the limited number of studies
that have employed observational methods, procedures and coding systems
have differed, making it somewhat difficult to compare findings across stud-
ies. Data reported in research studies only infrequently include reports from
or observations of the biological parents. Collection of data from biological
parents may allow for more fine grained analysis of previous attachment
relationships and behavior problems while in care and after reunification.
Finally, research and treatment studies often lack a control group preventing
a benchmark to compare children in the welfare system.
The ASFA of 1997 (Public Law 105-89) was created to promote the re-
unification of children and their families to a safe environment, while limiting
the time children spend in the welfare system and the number of placements.
States are evaluated on their ability to uphold this goal and much research
has been conducted to evaluate states’ progress. Despite the limitations of
previous research, one may readily conclude that a substantial proportion
of children who have entered the child welfare system will experience
significant and long-term mental health and adjustment difficulties. Mental
health professionals must continue to work closely with child welfare agency
staff to increase screening efforts and to provide more effective services to
 Adjustment in Foster Care Children 145

children and families in need. National policy changes are needed to bolster
the work of the dedicated—and all too often underresourced—staff working
on the front lines to improve outcomes for the vast number of children
who enter the system each year. The challenges are complex and simple
solutions illusory. Yet there is no doubt that meaningful change may be
obtained through collaborative action.

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CONTRIBUTORS

Andrea M. Jones is a graduate student at West Virginia University in Morgantown,

WV.

Tracy L. Morris, PhD, is a Professor in the Department of Psychology at West

Virginia University in Morgantown, WV.

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