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Possible Meanings and Implications

Richard P. Barth, MSW, PhD

Arch Pediatr Adolesc Med. 2008;162(6):(doi:10.1001/archpedi.162.6.586).

During the past 20 years, placement with relatives has become the preferred and most common type of foster care for children who have relatives able to assume their care. The study by Rubin et al¹ is one of the best ever performed on the outcomes of kinship care. Many background factors that could otherwise explain the lower rate of problem behavior for children in kinship care vs children in nonkinship care were controlled for with uncommon statistical sophistication.

Although the study¹ does its best to carefully compare outcomes for children in kinship care with those not in kinship care, the authors' conclusion that there is a "protective effect" still needs to be made with care. This could as accurately be called a "protective relationship" because we really do not know whether the better behavior of the children in kinship care is a cause or a result of their living with relatives or of some background differences. For example, Rubin et al note that the children in nonkinship care more often had parents with serious mental health problems who were more often using mental health services. In my view, the authors do not give these differences adequate weight because the relationship between such markers of mental health problems cannot easily be controlled for by statistical methods. Being in kinship care and having fewer behavior problems likely comprise a relationship that is too complicated to be thought of as being causal and one way.

The analysis was rigorous and controlled for the direct effects of kinship care, but it could not rule out the possibility that the selection of less troubled children into kinship care could interact with the provision of kinship care to result in improved outcomes. That is, more difficult children with significant mental health issues at entry into out-of-home care might do as well with kinship care. Or, they might do better.

Nevertheless, the findings are supported by other shorter-term (18-month) National Survey of Child and Adolescent Well-Being outcomes of lower Child Behavior Checklist scores for children in kinship care.² This related study measured the well-being of children in kinship care on a wider set of developmental measures and found no difference between the development for children in kinship care and for those in nonkinship care after using propensity score matching to select children who could hypothetically have been cared for in either form of care. The results suggest that the relationship between kinship care and better behavioral outcomes may not extend beyond the measure of behavior problems reported by caregivers.

The implications that the behavior problems of children in kinship care are fewer than those of children in nonkinship care are not obvious, as children cannot be assigned to kinship care rather than to nonkinship care if kin are unavailable. So, there may be some children whose behavior is so troubling that kin are unable or are unwilling to take them into their homes. The National Survey of Child and Adolescent Well-Being has no measure of this. It is also possible that when behavior begins to improve in foster care, children are then shifted to kinship placements that are not as specialized; this is what a well-functioning child welfare service program would aim to do. This would help explain why children who are moved later to kinship care do somewhat better than children who never move from foster care to kinship care, but this may not be how child welfare service operates.

It is also possible that foster parents rate the behavior of the children in their care as more problematic than do relatives. Although the Child Behavior Checklist is a well-used instrument, the meaningfulness of the findings is limited by self-report. Nevertheless, if the caregivers are more negative about their children, it is also possible that the children receive harsh treatment and that there is a greater likelihood that they will subsequently be moved. Therefore, the caregiver's perception of children's behavior may have real consequences for children. This is the basis for some new interventions that help shape foster parents' perceptions of children and that are having a salutary influence on the rate of placement changes, even for children who had many placement changes before.³

Rubin et al¹ are careful not to speculate about the reasons why the children in kinship care have fewer behavior problems than children in nonkinship care, given the likelihood that the children in kinship care receive fewer services. However, some speculation is needed to forward possible policy and program implications.

Placement instability is a salient predictor of developmental outcomes, possibly one of the key active ingredients in the creation of better outcomes for the children in kinship care. Because the authors controlled for placement stability, the lower number of placement moves may have contributed to a more predictable and less stressful environment that supports better behavior of the children, although this was not tested for outright in the study.¹ Kinship care may also operate through less stressful environments (fewer changes in cultural or behavioral expectations), and this is another reason why kinship care may favor the reporting of better behavioral outcomes by caregivers.

A broad implication of this study¹ is to endeavor to reduce placement moves for all children. A first option is to use 23-hour receiving centers that permit child welfare workers to provide a clean, safe, and entertaining place for a child to be brought by a first responder and then allow for a rapid assessment of the child and some time for the child welfare worker to locate relatives and get fingerprint clearance. Such a center does not carry the risk of shelters' becoming multiday, multiweek, and multimonth placements, which seem to be associated with worsening of children's behavior.⁴ However, support for these programs is difficult to muster because most child welfare funding is obtainable when children are in placements even if they are temporary, perhaps just the process that we need to prevent. More flexible rules regarding the use of federal child welfare funding streams are needed to support alternatives to placement. A second way to reduce multiple placements is to broaden access to programs that help foster parents to respond to the child's behavior more effectively and that provide components of a treatment foster care program approach shown to normalize cortisol release and reduce placement instability.^{1, 5}

The recommendations of the authors to expand the resources given to kinship providers with a national kinship guardianship program and to endeavor to more expeditiously notify kin and place children into kinship care deserve underscoring. These are low-cost strategies that deserve implementation given the evidence that children prefer to be placed with relatives and that the care of relatives may support better behavioral outcomes.

AUTHOR INFORMATION
Correspondence: Dr Barth, School of Social Work, University of Maryland, 525 W Redwood St, Room 5E14, Baltimore MD 21210 (RBARTH{at}ssw.umaryland.edu).

Published Online: June 2, 2008 (doi:10.1001/archpedi.162.6.586).

Financial Disclosure: None reported.

REFERENCES
1. Rubin DM, Downes KJ, O’Reilly A.L.R., Mekonnen R, Luan X, Localio R. Impact of kinship care on behavioral well-being for children in out-of-home care. Arch Pediatr Adolesc Med. 2008;162(6):550-556. FREE FULL TEXT 2. Barth RP, Guo G, Green R, McCrae J. Kinship care and nonkinship foster care: informing the new debate. In: Haskins R, Wulczyn F, Webb M, eds. Child Protection: Using Research to Improve Policy and Practice. Washington, DC: Brookings Institution; 2007:187-206.3. Fisher PA, Gunnar MR, Dozier M, Bruce J, Pears KC. Effects of therapeutic interventions for foster children on behavioral problems, caregiver attachment, and stress regulatory neural systems. Ann N Y Acad Sci. 2006;1094:215-225. FREE FULL TEXT 4. DeSena AD, Murphy RA, Douglas-Palumberi H; et al. SAFE Homes: is it worth the cost? an evaluation of a group home permanency planning program for children who first enter out-of-home care. Child Abuse Negl. 2005;29(6):627-643. PUBMED 5. Chamberlain P, Price JM, Reid JB, Landsverk J, Fisher PA, Stoolmiller M. Who disrupts from placement in foster and kinship care? Child Abuse Negl. 2006;30(4):409-424. PUBMED

RELATED ARTICLE

Impact of Kinship Care on Behavioral Well-being for Children in Out-of-Home Care
David M. Rubin, Kevin J. Downes, Amanda L. R. O'Reilly, Robin Mekonnen, Xianqun Luan, and Russell Localio
Arch Pediatr Adolesc Med. 2008;162(6):550-556.
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