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Navigating the complex behavioral landscape of children in foster care and adopted families

Navigating the complex behavioral landscape of children in foster care and adopted families

Article information

Clin Exp Pediatr. 2025;68(8):620-623
Publication date (electronic) : 2025 May 12
doi : https://doi.org/10.3345/cep.2025.00822
1A.T. Still University School of Osteopathic Medicine in Arizona - Arizona School of Health Sciences, Mesa, AZ, USA
2Family Healthcare Network, Visalia, CA, USA
Corresponding author: Sandhya J. Kadam. Family Healthcare Network, 4121 W Elowin CT, Visalia, CA, USA Email: hellosandhya7@gmail.com
Received 2025 April 10; Revised 2025 April 29; Accepted 2025 April 29.

Graphical abstract. Behavior concerns of children in foster care and adopted families.

Etiology of behavioral and mental health issues

Factors such as adverse childhood experiences, stressful environment during the preadoption period, preadaptive adversities such as exposure to maltreatment, neglect, abuse, and violence, uncertainty of placement instability, and genetic factors cause mental health issues in children in foster care and adopted families. In a study performed in 2022 by Engler et al. [1], those factors were found to be associated. Possible explanations of these problems are related to abandonment issues, identity development, separation from siblings and biological parents, and feelings of isolation. These children are more likely to encounter challenges in responding to the emotions of others, resulting in complex social interactions.

Other factors, including lack of resources, stigma related to mental health, geographic limitations, and financial issues, also make initial and follow-up mental health visits delayed, leading to the continuation of behavioral and mental health issues in these children [1].

Various mental and behavioral health issues

Studies have consistently demonstrated that foster children experience elevated rates of disorders, including aggression, oppositional defiant disorder, conduct disorder, major depressive disorder, posttraumatic stress disorder, academic issues, difficulties with emotional regulation, and reactive attachment disorder. Engler et al. [1] in 2022 concluded in their study that mental health issues were related to the maltreatment and placement type.

The increased rate at which these children display these disorders brings up the impact of placement settings and the impact of early adversity as well. Genetic and environmental factors influence the causes of these issues, necessitating a thorough exploration [2]. Likewise, adopted children encounter unique psychological and behavioral struggles, which are strongly influenced by the conditions and experiences within their pre- and postadoption environments. A systematic review by Duncan et al. [2] in 2021 revealed that mental health issues are influenced by the critical role of postadoption variables, which include new parent-child dynamics, family context, and broader environmental factors. Together, these insights emphasize how an integrative exploration of systemic factors is necessary to treat patients with an interdisciplinary approach to provide individualized plans related to the distinctive experiences of these children.

Possible factors affecting the placement of children

More than 400,000 children in the United States are living in foster care, and about 6% of all children experience foster care placement by age 18, as per the U.S. Department of Health and Human Services [3]. Age of the child greatly influences the occurrence of behavioral issues in children living in foster care and adopted families. These children are at higher risk of developing behavioral issues than the general population across all ages. However, certain age groups could be more vulnerable, such as early childhood, less than 5 years of age, and the adolescent age group, 13–18 years of age. Sattler et al. [3] in 2018 performed a study to know age-wise risk factors affecting the placement of these children in foster care. Placing children with relatives and trying to keep all siblings together resulted in substandard care. Other risk factors, such as gender and race, were studied, with findings of female and Hispanic children involved in child actions causing disruptions, and placement difficulties observed in Black children due to a mismatch or substandard care. In all age groups, adolescents were associated with the highest risk for placement disruptions. Uncertainty of placement is one of the main causes of behavioral issues in children living in foster care and adopted families.

Management strategies

Protective factors and interventions focusing on attachment and behavioral catch-up interventions show promising reductions in behavior problems. In the United States, a child who is placed in a foster home is brought to the pediatrician for a physical examination. Along with addressing the medical problems, patients are screened for possible anxiety with the Generalized Anxiety Disorder-7 and depression with the Patient Health Questionnaire-9 screening questionnaire. They also complete a questionnaire for adverse childhood experiences. Based on the history and score of the questionnaire, patients get referrals to behavioral health therapists and psychiatrists. Youth Services programs supporting mental health are available in almost every city, and programs from the youth crisis center, such as SNAP (Stop Now And Plan), help children manage their moods and emotions [4].

While addressing challenges faced by children in foster care and adopted children, it is essential to explore novel ideologies that move beyond traditional diagnostic therapies. For instance, it may be imperative to address how neurodevelopmental growth influences while dealing with trauma. Fostering an approach with that in mind can create a more effective treatment plan for each individual child. Research exemplified altered brain activity in children with previous traumas, in areas especially dealing with cognitive processing and emotional control [5].

This further confirms the need for treating children with previous adversities in a different manner than control groups. Ireton et al. [5] in 2024 utilized functional magnetic resonance imaging (fMRI) data to exemplify how the brains of those with previous trauma displayed atypical neural systems. This can help to study how soon adverse childhood experiences affect the brain and to start developing management skills to learn processing of emotions and self-regulation. fMRI studies can allow providers to reinforce compassion in treating these patients instead of thinking there is a deficit in the child.

However, the use of fMRI may have some limitations, especially the cost and availability. Due to differences in individual brain activity, establishing the reliability and generalizability of fMRI can become difficult. The complexity of interpretation related to behavior and fMRI signals could be another challenge, and fMRI signals may indicate the correlation but not the causation [6].

Not all children with behavioral issues respond to available standard options. Novel therapies will be useful for these subsets of children. Park et al. [7] in 2014 studied some of the pharmacological and nonpharmacological options for pediatric patients with anxiety, including augmentation of cognitive behavioral therapy, use of riluzole, a glutamergic agent, attention bias modification, and acceptance and commitment therapy.

Involvement of the family in parent-child interaction therapy is another approach to deal with behavioral issues in children. Naim et al. [8] in 2023 tested the rate of acceptance, efficacy, and feasibility of another novel therapy option, exposure-based treatment, in patients with severe irritability along with parent management skills. The results of the study supported the use of this exposure-based treatment option.

Additionally, discussing causes and management options of issues and developing a good rapport with capable children can bring a sense of empowerment to them. This may increase the response to behavioral therapy and can allow better communication between providers, children, and caregivers. This inclusive process may validate the child’s experiences and may create a sense of ownership and responsibility over their own treatments [9].

As important as it is to address deficits strictly within the child, it is also important to address the community and ecosystem the child is exposed to during developmental years. Traditional medical models tend to overlook the social environment of the child, which can undermine important correlations to the child’s behavioral disorder. A study by Chiang et al. [10], in 2024 showed that physical activities greatly influenced the behavior of children and even lowered aggressive behavior. Addressing broader cultural influences in the child’s behavioral makeup is imperative by going beyond recognizing individual and family dynamics.

Environments such as communities, schools, sports teams, and after-school activities must be included in treatment plans when evaluating the child’s behavioral concerns. Children, during their developmental years, heavily rely on social settings at school and extracurricular activities to shape and form their emotional responses to hardships. Such networks of multifaceted care can benefit from the complexity of behavior concerns in foster and adopted children [10].

Neuroplasticity strategies of mindfulness, visual, expressive arts, and physical exercise can help to improve the regulation of emotions and neural pathways. Community centers and focus groups could allow these children to engage in dialogues about their experiences and potential solutions, which can help to develop resilient and adaptive coping mechanisms supporting long-term mental, emotional, and cognitive well-being, along with building a sense of belonging and empowerment [6]. An interdisciplinary team and combination of traditional and novel ideas can optimize outcomes and overall quality of life. Based on these options, a multilayered plan can be developed to support children in foster care and adopted children [10].

Please refer to Table 1 for the summary of behavior concerns of children in foster care and adopted families and management strategies [1-10].

Summary of behavior concerns of children in foster care and adopted families and management strategies [1-10]

Conclusion

Various mental health challenges are faced by children in adopted and foster care. Assessing the child’s neurological development, empowering children to become active participants in their treatment, and formulating a more culturally sensitive plan, which may provide more effective management options. Support from foster parents, social workers, and healthcare professionals can help embrace innovative ideas to deal with behavioral concerns and transform the very fabric of care into a favorable environment.

Notes

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

This study received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.

Author Contribution

Author Choi, a physician assistant student, and Dr Kadam conceptualized and designed the study, drafted the initial manuscript, coordinated and supervised data, conducted the initial analyses, reviewed the manuscript for important intellectual content, and revised the manuscript.

References

1. Engler AD, Sarpong KO, Van Horne BS, Greeley CS, Keefe RJ. A systematic review of mental health disorders of children in foster care. Trauma Violence Abuse 2022;23:255–64.
2. Duncan M, Woolgar M, Ransley R, Fearon P. Mental health and behavioral difficulties in adopted children: a systematic review of post-adoption risk and protective factors. Adopt Foster 2021;45:414–29.
3. Sattler KM, Font SA, Gershoff ET. Age-specific risk factors associated with placement instability among foster children. Child Abuse Negl 2018;84:157–69.
4. SNAP (Stop Now And Plan) [Internet]. Jacksonville (FL): YouthCrisisCenter; [cited 2025 Mar 25]. Available from: https://youthcrisiscenter.org/our-programs/snap/.
5. Ireton R, Hughes A, Klabunde M. A functional magnetic resonance imaging meta-analysis of childhood trauma. Biol Psychiatry Cogn Neurosci Neuroimaging 2024;9:561–70.
6. Tsoi L, Burns SM, Falk EB, Tamir DI. The promises and pitfalls of functional magnetic resonance imaging hyperscanning for social interaction research. Soc Personal Psychol Compass 2022;16e12707.
7. Park JM, Geller DA. Novel approaches in treatment of pediatric anxiety. F1000Prime Rep 2014;6:30.
8. Naim R, Dombek K, German RE, Haller SP, Kircanski K, Brotman MA. An exposure-based cognitive-behavioral therapy for youth with severe irritability: feasibility and preliminary efficacy. J Clin Child Adolesc Psychol 2024;53:260–76.
9. Montori VM, Ruissen MM, Hargraves IG, Brito JP, Kunneman M. Shared decision-making as a method of care. BMJ Evid Based Med 2023;28:213–7.
10. Chiang HL, Chuang YF, Chen YA, Hsu CT, Ho CC, Hsu HT, et al. Physical fitness and risk of mental disorders in children and adolescents. JAMA Pediatr 2024;178:595–607.

Article information Continued

Table 1.

Summary of behavior concerns of children in foster care and adopted families and management strategies [1-10]

Behavior concerns Management strategies
Fear of abandonment Build a sense of security through a predictable routine
Aggression, emotional outbursts Set clear boundaries and coping strategies
Attachment issues Build trust through patience and consistency
Mood swings Techniques for emotional regulation
Trust issues Clear open communication
Offer choices and respect autonomy
Low self-esteem Positive reinforcement
Offer comfort and praise
Try new things to boost confidence in a safe environment
Oppositional defiant Open communication
Respect autonomy
Establishment of clear, consistent rules and expectations
Poor school performance Coordination with teachers & counselors
Additional tutoring at school
Regression behavior Find the triggers for regression
Provision of love, comfort, and reassurance
Hyperactivity and inattention Structured routine breaks
Evaluation for ADHD
Referral to therapy
Evaluation for ADHD medications

ADHD, attention deficit/hyperactivity disorders.