The views expressed herein have not been approved by the House of Delegates or the Board of Governors of the American Bar Association, and accordingly, should not be construed as representing the policy of the American Bar Association.
Children entering the foster care system are a highly vulnerable population who suffer from high rates of chronic health conditions, including malnutrition and other food-related problems. One study shows that about 20% of children in foster care are of short stature, a possible sign of malnourishment due to neglect, with an additional 6% to 10% of infants and toddlers meeting criteria for failure to thrive.1 On the other extreme, about 15% of children in foster care meet criteria for obesity, and data indicates that this figure is continuing to rise.2
Failure to Thrive
One form of malnutrition that disproportionately affects children who have entered foster care is a history of physical growth failure, or failure to thrive (FTT). FTT is primarily caused by nutritional deficiency, which can lead to developmental delays and aberrant behavior in children, and may be a sign of poor feeding or neglect.3 Children in foster care are more prone to FTT as a result of malnutrition because of the poverty, limited access to food, or neglect that they may experience before entering care.
An important indicator of FTT is short stature, defined as height below the 2.5 percentile for one’s sex, which may occur as a result of early emotional deprivation and inadequate prenatal and/or postnatal nutrition.4 Height for age also has a significantly negative correlation to the neglect that a child experiences, and may be a sign of chronic malnutrition.5 Studies of the physical growth of children in foster care indicate that their average height tends to be shorter than children not in care.6 In addition, significantly more children in foster care meet the criteria for FTT as compared to children not in care.7
Early Brain Development
Since FTT is prevalent among infants and toddlers, it is important to understand the effects of inadequate nutrition on the physical growth and brain development of young children. According to preliminary estimates by the Adoption and Foster Care Analysis and Reporting System (AFCARS) for fiscal year 2009, 31% of all children in foster care are less than five years old, and it is precisely during these years that brain structures affecting personality, learning, and emotions are forming.8
The nerves and neurotransmitters responsible for these brain formations are negatively influenced by abuse and neglect.9 Because the nutritional requirements of infants is high, any caloric or nutrient deficiency has the ability to severely impair mental development in young children by delaying, or in extreme cases, even preventing these brain structures from growing.10 The long-term consequences extend beyond poor growth, including deficits in social, psychological, and intellectual functioning.11
Fortunately, studies show that children who experience growth delays early in life are likely to catch up to normal height for age and improve their cognition with nurturing caregiving.12 Since growth delay is secondary to environmental factors, including nutrition, catch-up growth can be maximized by promoting nurturing caregiving and improving access to healthy foods.13
Foster Parent Education
One way of promoting nurturing caregiving is to educate foster families about the special nutrition needs of children in care and the food-related problems they may encounter. The SPOON Foundation, which aims to improve the nutrition of orphaned, fostered, and adopted children, partnered with the Joint Council on International Children’s Services to create AdoptionNutrition.org. This Web site contains valuable resources on nutrition and food for foster and adoptive families, including contributing factors to malnutrition, and information about feeding difficulties and FTT.
The Alaska Center for Resource Families created a guide for foster parents to help them understand state regulations regarding the nutritional health of their children, including the prohibition of force-feeding and using food as punishment, and advice on how to deal with behavior such as overeating or hiding food. The guide also recommends that foster parents regularly provide healthy and nutritious meals, restrict access to “junk” foods, and constantly remind children that they will be fed again in order to prevent uncertainty about their access to food—an insecurity that may lead to eating disorders or other health issues.14
One young adult and former foster child was sporadically given unhealthy meals to eat in the attic of her foster family’s home, leading her to hoard food and overeat as a teenager. She did not know how to cope with her experiences, and was never told what was healthy for her to eat or the importance of proper nutrition. The malnutrition that she experienced in her foster placement has contributed to the gastrointestinal problems that she now endures years after leaving care. She believes that nutrition education should be a mandatory part of every state’s training for foster parents, including how to care for children who have previously experienced malnourishment.
On the other end of the spectrum, obesity has been affecting the health of more children in foster care, and is now even more widespread than FTT.15 On July 13, 2011, the Journal of the American Medical Association published an article about state intervention in cases of life-threatening childhood obesity,16 a topic that has recently been gaining national attention.
However, there have been findings that children in foster care may actually experience an increase in their body mass index (BMI) while in care.17 In fact, many former foster children describe an abundance of pastas, sodas, and other unhealthy foods in out-of-home care. In addition, children in group homes are often given time limits to complete a meal. These conditions may lead to behaviors such as overeating or eating too quickly, and can result in long-term health problems. Another contributing factor to the rise in obesity could be that foster parents are sensitive about upsetting the child by restricting food choices at home, or are afraid of being reported for child neglect due to inadequate food
One former foster youth recalls a lack of physical activities in the group homes he attended due to liability issues and worries about the children getting injured. This resulted in relying on sedentary activities such as watching TV and playing videogames for entertainment. He recalls leaving foster care desperate for fresh air and exercise. Several foster care organizations are trying to prevent this through physical activity programs.
For example, the Sierra Association of Foster Families in Nevada offers Zumba dance classes for children in an effort to reduce obesity and increase self-esteem. Similarly, the nonprofit organization Happy Trails for Kids provides a free summer camp for children in the California foster care system that promotes healthy eating and includes outdoor activities such as swimming and hiking. Since a lack of physical activity is one factor that leads to obesity, these fitness programs are effective in helping to reduce
Another way to improve the nutritional health of children in foster care is to provide training for cooks in group homes. Many of these cooks lack the expertise to prepare large quantities of healthy foods for children, and can benefit from additional training in food preparation. One way to facilitate this training is to have the state agency employ nutritionists, or have local chefs volunteer their time to teach healthy cooking methods to cooks in area foster homes.
Foster youth often feel ill-equipped to grocery shop and prepare meals once they exit care, relying on fast foods for meals. They suggest that cooking classes and nutrition education be incorporated into foster care before and during the transitional period—as early as age 14. Attorneys on Youth Advisory Boards can act as mentors and raise issues related to food and nutrition on behalf of children in out-of-home care, while informational tools for caregivers and fitness programs for children in care should be expanded, or even required, so that they serve as many families as possible who may not otherwise be able to access these resources.
Poverty and Food Insecurity
One of the greatest risk factors for nutrition problems is poverty. Poverty is also one cause of food insecurity, or the struggle to consistently get enough food to eat. It is well known that children in foster care often live in families with incomes below the federal poverty line, making them six times more likely to have low food security than children in households with incomes at 185% of poverty or higher and 14 times more likely to experience very low food security.20
Although food insecurity plays a role in child undernourishment, it is also associated with weight gain, since the inconsistent availability of food may result in lower-quality diets and overeating.21 Food insecurity may also play a role in eating disorders among children in foster care, especially hyperphagia (overeating), pica (eating inedible objects), food hoarding, and bulimia nervosa in older youth.22
Children who live with kinship caregivers may be exposed to additional risk factors. The results of a national survey indicate that 51% of children in kinship foster care compared to only 24% of children in non-kin foster care experienced food insecurity.23 It is not only lower income levels that affect kinship caregivers, but studies show that kinship caregivers also are more likely to be single, tend to be older, and have worse health than non-kinship caregivers.24 The compounding effects of poverty and these other risk factors on food insecurity and poor nutritional outcomes is substantial, and should be considered when developing programs and services to improve the nutritional health of children in foster care.
Supporting Healthy Nutrition
WIC—Based on the evidence that nurturing caregiving combined with better access to healthy foods has the potential to improve growth in very young children, federal programs have been created to specifically serve the nutritional needs of this vulnerable group. Federal policy for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) states that all pregnant, postpartum, and breastfeeding mothers and children under five years of age who meet income and nutrition risk guidelines are eligible for its programs, which provide supplemental food assistance, nutrition education, and health and social service referrals for mothers and their children.25 Studies show that just one hour-long WIC infant-care training session that focuses on nutrition education and early brain development has positive effects on the confidence and knowledge of foster parents.26 In addition, WIC participation is associated with a higher intake of crucial nutrients, while calorie intake is not significantly different than that of non-WIC children.27
Mothers and children who apply for WIC hear back about their eligibility within 20 days, or 10 days if the applicant has a special nutritional risk. Although there is a waiting list, it has not been used for several years because Congress has provided a funding level high enough to serve all WIC participants. State and local WIC agencies are required to facilitate the administration of services by providing extended hours and language interpreters when needed. To further simplify the application process, the Food and Nutrition Service is developing an online prescreening tool that is expected to be available by the end of this year. This tool will allow individuals to determine their eligibility based on income and make an appointment at the nearest WIC agency.
No provision in WIC allows children in foster care to be categorically eligible for benefits. However, children in foster care who are under five years old or who are pregnant teenagers will more than likely qualify for income because a child in foster care is considered to be a one-person household whose income is only represented by the state or county payments to the foster parents.
Children in foster care may also be eligible for income based on their participation and certification for Medicaid or TANF. Attorneys and advocates should be aware that children in foster care who meet the age requirements are often eligible for WIC benefits. Advocates should
encourage eligible mothers, fathers, and other caregivers to enroll their foster children for WIC to improve their nutritional health and outcomes. For more information about WIC eligibility and services, including the Farmers’ Market Nutrition Program, see www.fns.usda.gov/wic/.
Healthy, Hunger-Free Kids Act—The federal Healthy, Hunger-Free Kids Act (the Act),28 signed into law by President Obama on December 13, 2010, authorized an additional $4.5 billion in funding towards improving the quality and accessibility of federal food programs that serve children in schools. The Act allows children in foster care to be categorically eligible for free school meals regardless of family income, and without having to submit an application.
Since the Act was passed, foster children placed with relatives or nonrelatives through a child welfare agency or court are categorically eligible for free meals in school or child care regardless of family income. Unfortunately, children in subsidized guardianship placements or informal kinship care and not in the foster care system are not categorically eligible under these provisions, but may be eligible for other reasons such as income. For example, any child (foster or non-foster) who lives with a household member who receives SNAP benefits (formally known as the Food Stamp Program) is entitled to free meals, even if not a recipient him or herself.
Attorneys and judges should find out if children in foster care are currently being approved and enrolled for free meals at school or daycare, and if not, should raise this issue at court hearings. Attorneys should ask the child welfare agency or court to provide documentation of a child’s foster care status directly to the school or child care provider so the child can be approved for free meals on that basis.
Attorneys and advocates can help foster parents fill out school meal applications if proper documentation is not directly provided to the school by the agency or court. They can also help foster parents understand that including their foster child on a meal application may help their non-foster children qualify for free or reduced price meals by increasing their household size.
Child advocates and parents’ attorneys should also work with parents who are trying to reunify with their children to ensure they understand these nutrition-related issues and have access to healthy foods for their children. For more information on the categorical eligibility of children in foster care under the Act, see this USDA memo.
If malnutrition is suspected in a child abuse or neglect case, attorneys should talk to the child’s doctor and ask for a comprehensive nutritional evaluation of the child. This type of evaluation can uncover whether a child meets criteria for FTT, which is important to consider when planning an intervention.
Advocates can also address obesity issues by encouraging the expansion and accessibility of nutritious foods and fitness programs for children in care and by informing foster parents about the importance of proper feeding and healthy social interactions, especially with infants and toddlers. If a child has already been identified as having FTT or obesity, a treatment plan must be created and caregivers should understand how to adhere to that plan.
Attorneys, judges, and other child advocates can ensure that children in care have access to nutritious meals and are receiving services that help them stay physically active and healthy. In addition to federal efforts to increase access to nutritious meals, many communities offer low-cost, easily accessible programs. Early identification of food-related health issues among children in care is key, as well as educating and supporting caregivers’ efforts to address them.
The author thanks Howard Davidson, Eva Klain, Claire Chiamulera, FosterClub and Donna Hines of the USDA Food and Nutrition Service for their contributions.
Noora Barakat is a student majoring in child development and American studies at Tufts University in Medford, MA. She interned at the ABA Center on Children and the Law in summer 2011, and will be attending law school next fall to study child welfare issues.
1 Szilagyi, Moira. “The Pediatrician and the Child in Foster Care.” Pediatrics in Review 19, 1998, 39-50.
3 Downer, Dr. Goulda A. Interview by Claire S. Chiamulera. “What Advocates Should Know about Child Malnutrition and Neglect.” Child Law Practice 25(6), August 2006, 92-95.
4 Szilagyi, 1998.
5 Pears, Katherine and Philip A. Fisher. “Developmental, Cognitive, and Neuropsychological Functioning in Preschool-aged Foster Children: Associations with Prior Maltreatment and Placement History.” Journal of Developmental & Behavioral Pediatrics 26, April 2005, 112-22.
7 Szilagyi, 1998.
8 Committee on Early Childhood, Adoption and Dependent Care. “Developmental Issues for Young Children in Foster Care.” Pediatrics 106, November 2000, 1145-50.
11 Klain, Eva J., et al. “Promoting Physical Health.” Healthy Beginnings, Healthy Futures: A Judge’s Guide. Washington, DC: ABA Center on Children and the Law, 2009. Print.
12 Johnson, Dana E. et al. “Growth and Associations Between Auxology, Caregiving Environment, and Cognition in Socially Deprived Romanian Children Randomized to Foster vs. Ongoing Institutional Care.” Archives of Pediatrics & Adolescent Medicine 164, June 2010, 507-16.
13 Oliván, Gonzalo. “Catch-up Growth Assessment in Long-Term Physically Neglected and Emotionally Abused Preschool Age Male Children.” Child Abuse & Neglect 27, February 2002, 103-08.
14 To view The Alaska Center for Resource Families guide on nutrition and children in foster care, see: “Understanding the Regulations: What Alaskan Foster Parents Need to Know.” #4 Nutrition and Eating in the Foster Home. Available at: www.acrf.org/Self-StudyCourses/RegulationSeries/Regulations4Course.pdf
15 Klain, 2009.
16 Murtagh, Lindsey and David S. Ludwig. “State Intervention in Life-Threatening Childhood Obesity.” Journal of the American Medical Association 306, July 2011, 206-07.
17 Hadfield, Sarah C. and Philip M. Preece. “Obesity in Looked After Children: Is Foster Care Protective from the Dangers of Obesity?” Child: Care Health & Development 34, May 2008, 710-12.
18 Klain, 2009.
19 For more information about physical activity and obesity, see: National Institute of Child Health & Human Development. “Obesity/Overweight.” Available at: www.nichd.nih.gov/health/topics/Obesity.cfm.
20 Murphey, David, Bonnie Mackintosh, and Marci McCoy-Roth. “Early Childhood Policy Focus: Healthy Eating and Physical Activity.” Child Trends: Early Childhood Highlights 2, July 2011, 1-7.
22 Heller, Sherryl Scott and Anna T. Smyke. “Very Young Foster Children and Foster Families: Clinical Challenges and Interventions.” Infant Mental Health Journal 23, September 2002, 555-73; Pecora et al. “Assessing the Effects of Foster Care: Mental Health Outcomes from the Casey National Alumni Study.” The Casey Foundation, 2005.
23 Ehrle, Jennifer and Rob Geen. “Kin and Non-kin Foster Care—Findings from a National Survey.” Children and Youth Services Review 24, January 2002, 15-35.
25 For details about WIC categorical eligibility requirements, see: WIC. “How to Apply.” Available at: www.fns.usda.gov/wic/howtoapply/eligibilityrequirements.htm.
26 Gamache, Susan, Dianne Mirabell, and Lisa Avery. “Early Childhood Developmental and Nutritional Training for Foster Parents.” Child and Adolescent Social Work Journal 23, December 2006, 501-11.
27 Davaney, Barbara. “WIC Turns 35: Program Effectiveness and Future Directions.” National Invitational Conference of the Early Childhood Research Collaborative. December 2007.
28 Healthy, Hunger-Free Kids Act of 2010, Pub. L. No. 111-296 (2010).