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Raising a child outside the child’s biological family of origin, as in foster care or adoption, presents a unique set of psychosocial challenges involving an interplay between transition and adaptation. The child must contend with separation from and possible reunification with the birth parent, adjustments to 1 or more families, and changes in physical environment, social support, and care providers. The foster or adoptive parents are challenged with helping the child integrate into a new family, taking into account the child’s previous experiences, and facing the possibility of further transitions in the future. The child’s and family’s success in adapting to these changes in care are influenced by a complex interaction between innate, individual capabilities and external resources. Nowhere is the traditional role of the pediatric provider more important in providing continuity of care, family guidance, and support for the physical, neurodevelopmental, and emotional needs of the child and family.

Foster Care

Approximately 500,000 children are in foster care on any given day with about 800,000 children being served by the foster care system in a year.1 In contrast to the early years of foster care when foster placement often resulted because of illness or death of parents or extreme poverty, approximately 70% of children today are placed because of parental abuse and/or neglect; more than 80% of children who enter foster care have a parent who abuses drugs or alcohol.

Children enter foster care for a variety of reasons, including the negative impact of acute and chronic family stressors, abandonment, parental inability to care for a child, homelessness, parental substance abuse, and increasingly, child neglect and/or physical and sexual abuse. Foster care is intended to be a temporary legal arrangement in which the child is protected and nurtured while supportive services are provided to the biological parent(s) to achieve family reunification.


As of 2004, an estimated 1.6 million children under 18 years of age lived with adoptive parents and approximately 2.5% of US families had an adopted child. Approximately 127,000 children are adopted in the United States each year. The percentage of all adoptions by type is represented in Figure 20-1. Public agency and intercountry adoptions have grown significantly and now account for more than half of all adoptions. Approximately 10% of all adoptions are voluntarily relinquished infant adoptions. Increasing numbers of children are being adopted by transracial, transcultural, single-parent, and same-sex couples.2 Slightly more girls than boys are adopted. The trend toward international adoption has also risen steadily with approximately 20,000 children having been adopted from foreign countries in 2006.3 Currently, the largest representation is from China, Guatemala, South Korea, Russia, and Ethiopia. The majority of children adopted internationally are under age 4 years, often under age 1, and female.

Figure 20-1.

Percentage of US adoptions by type. ...

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