Analysis of Caregiver Factors and Placement Instability in Foster Care from a Trauma-informed Perspective

Abstract

Placement disruption and related factors are of increasing concern in foster care systems in the United States. The majority of children in foster care in the United States for 24 months or longer experience three or more placements, with children with special needs experiencing an average of four or more foster placements (Leathers et al., 2019; Platt & Gephart, 2022; Skoog et al, 2015). The impact of this placement instability and corresponding losses is significant on children, families and the system itself. Most studies to date have focused on the challenging behaviors of children and other child factors as being the primary contributors to placement disruption. This study aims to expand the analysis of additional factors from a trauma-informed perspective. In this large sample (N = 1213) from a statewide foster care system in the United States, bivariate and multivariate analyses found that caregiver factors including intensity of exposure to child's trauma, sense of competence, support, and years of foster parenting experience accounted for approximately 26% of the variance in the number of placement disruptions observed. These findings suggest multiple points of entry for trauma-informed intervention and training efforts to support caregivers and promote placement stability in foster care.

Headnote

Placement disruption and related factors are of increasing concern in foster care systems in the United States. The majority of children in foster care in the United States for 24 months or longer experience three or more placements, with children with special needs experiencing an average of four or more foster placements (Leathers et al., 2019; Platt & Gephart, 2022; Skoog et al, 2015). The impact of this placement instability and corresponding losses is significant on children, families and the system itself. Most studies to date have focused on the challenging behaviors of children and other child factors as being the primary contributors to placement disruption. This study aims to expand the analysis of additional factors from a trauma-informed perspective. In this large sample (N = 1213) from a statewide foster care system in the United States, bivariate and multivariate analyses found that caregiver factors including intensity of exposure to child's trauma, sense of competence, support, and years of foster parenting experience accounted for approximately 26% of the variance in the number of placement disruptions observed. These findings suggest multiple points of entry for trauma-informed intervention and training efforts to support caregivers and promote placement stability in foster care.

Placement disruption and related factors are an ever-present and increasing concern for foster care systems. The majority of children who are in foster care in the United States for 24 months or longer experience three or more placements, with children with special needs experiencing an average of four or more placements (Leathers et al., 2019; Platt & Gephart, 2022; Skoog et al., 2015). The impact of these frequent placement disruptions and subsequent moves is significant. Children experience considerable loss across domains including friends, siblings, and contact with other family members, and they must adapt to new families, neighborhoods, and schools (Fawley-King et al., 2017). Placement disruptions have been found to relate to significant adverse effects on children's emotional, behavioral, relational, developmental, and academic functioning as a result (Konijn et al., 2019; Oosterman et al., 2007; Vreeland et al., 2020). In addition, placement disruptions also present human and financial costs to foster families and associated professionals and organizations (Taylor & McQuillan,2014). This study aims to further explore factors associated with the significant problem of placement disruption to provide more information to guide related prevention and intervention efforts.

Foster care is one of the most robust interventions and resources available to children who have experienced maltreatment. Many studies have shown improvements in child outcomes regarding safety, education, and delinquency for children in foster care though results are mixed depending upon placement stability and other factors, and the demand for these resources has intensified in recent years (Blodgett, 2022; Gross & Baron, 2020). Child maltreatment and the need for out of home care placementis a significant issue in the United States, with approximately 700,000 children requiring placement in foster care annually and over 400,000 children being actively fostered (U.S. Department of Health and Human Services, 2019). The number of children in need of placement exceeds the number of homes available in most areas since the implementation of the Family First Prevention Services Act (FFPSA) of 2018, largely due to its focus on transitioning youth from residential programs to therapeutic foster care (Tullberg et al., 2019). As a result, foster care systems in the United States are taxed by the demands of caring for higher volumes of youth with increasing levels of therapeutic need. Rates of mental health diagnoses are extremely high for children in foster care. For example, rates of posttraumatic stress disorder (PTSD) in this population range from 18-64% (Salazar et al., 2013; Whitt-Woosley, 2018) indicating the need for not only therapeutic but trauma-sensitive caregiving. Studies are increasingly documenting the impact of caring for numerous trauma-affected children on foster parents, as evidenced by their high rates of secondary traumatic stress and burnout (DowdyHazlett & Clark, 2024; Whitt-Woosley et al., 2020). These are just some of the factors that present challenges to placement stability and contribute to risks for placement disruption in foster care for youth who have experienced maltreatment.

A review of the current body of literature suggests that there are a multitude of factors from various domains contributing to risks for placement disruption in foster care. Factors associated with children and child behavioral challenges have been documented most frequently as these are central factors that tend to interact with other contextual variables associated with placement instability. In the literature, multiple sources conclude that the age of a child at time of placement considerably impacts stability, as older children seem to disrupt more often than their younger peers (Finster & Nowalk, 2021; Vreeland et al., 2020; Weiner et al., 2011; Oosterman et al., 2007). Some also found that race was correlated with a childs likelihood to disrupt, with Black or Native American children seeming to experience more instability (Platt & Gephart, 2022). Additionally, difficulty with behavior is cited extensively as a primary contributing factor for disruption, with many articles citing problems in school (Vreeland et al., 2020), internalizing and externalizing behaviors (Vitela, 2013), risk to others (Leathers et al., 2019), and affect dysregulation (Vreeland et al., 2020) as significant predictors of placement disruption in foster care. Across studies, the conclusion seems to be that behavioral challenges are consistently a strong predictor of disruption in the foster care setting (Leathers et al., 2019; Fisher et al., 2011; Weiner et al., 2011) A high number of previous placements (Vreeland et al., 2020; Oosterman et al., 2007), disability (Platt & Gephart, 2022), a greater amount of time spent in the foster system (Leathers et al., 2019), reentering foster care (Finster & Norwalk, 2021), and increased exposure to trauma (Weiner et al., 2011) were also shown to be positively correlated with disruption. Conversely, placement of a child outside of their home state appears to be somewhat protective in that it associates with fewer placement disruptions (Platt & Gephart, 2022).

Studies on placement disruption factors related to caregivers are less numerous. However, in the existing literature many studies have found possible links between age and marital status with regard to disruption, with married couples seeming to disrupt less often (Platt & Gephart, 2022) and older parents appearing to disrupt more frequently (Tunno, 2015; Platt & Gephart, 2022). A few other studies focus on the impact of foster parents'levels of experience, training,and support as being mitigating factors (Alexander, 2021; Taylor & McQuillan, 2014; McKeough et al., 2017). Emotional connection, specifically, also seems to be a primary focus of many of these studies, with several measuring attachment, connectedness, warmth, communication, and quality of foster parenting, all of which were established as serving a protective function (Barnes, 2022; Bernedo et al., 2015; Whenan et al., 2009). It has been posited that perhaps the increased connectedness and continuity with family and culture is why children often fare better in kinship vs. foster placements as race and ethnicity have been found to be potential factors in disruption, but more research on this potential link is needed (Hassall et al.,2021). Overall, the impact of placement with kin has demonstrated mixed results with regard to placement stability, with some studies showing it may increase the likelihood of disruption related to inadequate care and supportive resources (Sattler et al., 2018). Other studies show that it may decrease the probability of disruption (Chamberlain et al., 2006), and still others find no relation at all between disruption and kinship placement (Oosterman et al., 2007).

In addition to individual influences, there are several factors inherent to the foster care system itself that impact placement stability. The primary systems-level factor across studies seems to be training and support for parents, especially those who are new to the foster care system (Alexander, 2021). Research has shown that collaboration, feeling like a valuable member of the care team, and receiving adequate support can influence the outcome of placements in a significant manner, and parents who have reported deficiencies in these areas are more likely to disrupt (Tonheim & Iverson, 2018; Alexander, 2021). Caseworker turnover (Alexander, 2021), increased number of children placed in the home (Chamberlain et al.,2006), and differences between a child's needs and a foster family's ability to provide care (Tonheim & Iverson, 2018) have all been cited as increasing the likelihood of placement disruption as well. Additionally, contact with biological parents has been suggested as a factor that can contribute to the likelihood of disruption, though the exact implications of this seem a bit unclear, with some suggesting that positive interactions via visitation can actually improve placement stability (Chamberlain et al, 2006) while others indicate that contact decreases the likelihood of stability (Terling-Watt, 2001). Finally, location or geography is thought to play a significant role in disruption as children located closer to therapeutic resources and supports exhibit decreased risk for placement breakdown and disruption (Weiner et al, 2011).

While the current body of literature provides some information and context for understanding placement disruption in foster care, there are many remaining questions and notable gaps that support the need for ongoing research on this topic. First, most of these studies were conducted with very small, non-randomized samples and therefore are of limited generalizability. The majority of research conducted to date also has focused primarily on child factors and the contributions of child behavioral problems as contributing factors to placement disruptions in foster care, with other factors such as those relating to caregivers or systems issues being included to a lesser degree or more briefly mentioned in child-focused studies. Lastly, nearly all of these studies did not include any trauma variables in their investigations. Only one quantitative study was found that included the number of traumas a child had experienced as a variable, which was found to be a significant predictor of placement disruption in the sample (Weiner et al., 2011). One other qualitative study was found to include a trauma perspective. This study identified prior trauma history for both youth and foster parents as notable themes related to placement disruptions (Alexander, 2021).

The current study aims to explore some of these gaps in the literature regarding placement disruptions in foster care. Research questions regarding what caregiver and trauma factors relate to placement disruptions were examined in a large sample from a statewide survey of foster parents. A data-driven approach was used to examine what specific factors would associate with increases in placement disruptions. The purpose of this study is to clarify the understanding of the role of caregiver and trauma-related factors to inform trauma-informed prevention and intervention efforts to stabilize placements in foster care.

Methodology

Sample

An electronic survey was distributed in late 2019 via email to all active foster parents (state and private agency) in a predominantly rural, Southeastern U.S. state. This state has a hybridized foster care system comprised of a state-operated agency and multiple privately operated foster care agencies. All foster parents serving both state-operated and private agencies are required to be at least 21 years of age, financially stable, in good health, and citizens of the United States. The survey was sent to a total of 3,327 individual foster parents, with 1,213 respondents completing the survey resulting in a 36% response rate. While other surveys of all foster parents in a statewide system were not available for comparison, this robust response rate was likely the result of multiple follow-up reminders and the support of the state and private foster care agencies with the initial distribution of the survey. Respondents were provided the opportunity to participate in this study anonymously online via a cloud-based service. Page one of the survey included the full explanation of the study's purpose, procedures and duration. Risks and benefits were explained in addition to the voluntary and confidential nature of the study. In order to continue the survey, participants were required to indicate their acceptance of these terms. No identifying data was collected, and participants were provided a small, one-time payment for completion of the study. A separate link to complete the payment process was provided to maintain anonymity and participants were asked if they would like to be included in a follow-up interview via the same link. This study was approved by the university and state child welfare agency Institutional Review Board.

Descriptive information regarding the sample was obtained from the survey. The final sample of certified foster parents who responded to the survey represented a range of ages from 22 to 73 years (mean = 41.6, SD = 9.9). This survey was limited to certified foster parents receiving the full range of resources and did not include kinship care providers. Most respondents identified as female (80.5%) and White (93.5%), which is consistent with the general population of the Southeastern state sampled for this study. The sample reported rates of educational attainment at 34.7% with college degrees and 26.3% with graduate degrees. The majority of foster parents also reported that they were married (83.4%) and worked for the state-operated foster care agency (72.3%; 27.7% private child care agency). Most respondents identified as basic level care providers (60.8%), with 31.6% therapeutic level and 7.5% identifying as medically complex foster parents.

Additional questions were asked about foster parenting experiences. The sample participants reported an average number of years of experience with foster parenting as 4.7 years (SD = 5.2, range 1-46 years), and an average total number of children in their care as 11.4 (SD = 26.1, range 1-500). The average number of members of household at the time of the survey was 4.9 (SD = 1.9, range 1-13) and the average number of placement disruptions reported was 1.3 (SD = 2.7, range 0-30). Table 1 contains additional descriptive information regarding the sample.

Measures

The full survey included various items requesting demographic information, information about experiences specific to foster parenting and questions regarding related supports and resources. Questions regarding exposure to information regarding their children's trauma experiences were included, as were established measures of secondary traumatic stress and burnout.

Dependent variable. The dependent variable of placement disruption was measured on the survey by asking foster parents, "How many placement disruptions of children in your care have you experienced due to factors other than the child was successfully returned to or placed in a permanent caregiving arrangement?" Responses were coded as a continuous variable without a specified range.

Independent variables. The independent variables selected for this study included foster parent type, experience, practical support, child trauma exposure, and sense of competence. Foster parents were asked to endorse if they were basic care foster parents, therapeutic foster parents, or medically complex foster parents. These variables were coded ordinally based on the necessary qualifications associated with increasing caregiving demands from basic to medically complex. Years of experience were measured by asking them to report the total number of years they had been an active foster parent in whole numbers. Caregiver support was measured on a ten-point Likert scale in terms of practical support in the foster parenting role (defined as having "people or resources you regularly use to assist you with the tasks of caregiving") and emotional support (defined as having "people or resources you rely on to assist you with the emotional challenges of caregiving"). Dose of child trauma exposure was measured by having the foster parents rate on a five-point Likert scale the estimated amount of trauma details to which they had been exposed, ranging from "none at all" to "а lot." Sense of competence was measured by asking foster parents to respond yes or no to the item, "I did not feel capable of managing my child's needs."

Indicators of STS and associated levels of distress and functional impairment were also measured for this study and included in some of the descriptive and correlational analysis. The Secondary Traumatic Stress Scale (STSS) for DSM-5 (B. Bride, personal communication, October 5, 2017) was used to measure the foster parents' self-reported, total symptoms of secondary traumatic stress. The STSS has demonstrated good validity and reliability across studies of helping professionals and in one study of foster parents (Bride et al., 2004; Hannah & Woolgar, 2018; Ting ег al., 2005). The Cronbach's Alpha for the total STSS scale (.91) used in this analysis showed good internal reliability with this sample.

Additional variables regarding the intensity of STS symptoms and associated functional impairment were also measured. To measure intensity of STS symptoms, foster parents were asked to rate on a five-point Likert scale (none to extremely) how much they had been bothered by their thoughts and feelings regarding their child's trauma in the past month. Similarly, they were asked to rate on the same scale how much these thoughts and feelings had impacted their functioning in the past month in the domains of relationships with other people, ability to work, or in general (parenting, housework, schoolwork, volunteering, etc.).

Results

The results of this study were analyzed using the SPSS 29.0 statistical software, which was first employed to conduct descriptive and bivariate analyses. A review of existing literature drove the initial selection of variables. The findings from the univariate and bivariate analyses were subsequently used to select variables for a multiple regression model testing the relationships of these factors to placement disruptions in foster care.

Table 1 contains the results of the univariate analyses, specifically demographic and descriptive statistics from the sample population. As noted in the table, this population of foster parents reported a high level of practical and emotional support, at an average of 7.2 and 7.1 on a scale of 1-10 respectively. They also reported on average, a moderate degree of total symptoms of secondary traumatic stress (34.), but mean burnout scores were in the low range (21.9). Additionally, it was found that exposure to child trauma was extremely common, with more than two thirds (67.6%) of parents reporting they had been exposed to a moderate or extensive number of trauma details relating to the children in their care. The primary sources of this information were reported as caseworker reports (53.3%) or reports from the children themselves (48.6%). Other descriptive variables measured potential contributors to placement disruptions with the most commonly endorsed item being that the child's mental health needs were too severe (22.5%), the child's disruptive impact on the family (26.4%), and not feeling capable of meeting the child's needs (15.7%).

Bivariate analysis of the variables revealed numerous statistically significant relationships. However, most correlations to the dependent variable of placement disruption were significant but in the weak to moderate range (from r = 15 to r = .39). The strongest relationships to placement disruption were with ability to meet the child's needs (»=.39, р < .001), years of experience (7 = .39, p < .001) and intensity of exposure to child trauma (7 = .25, p< .001). It was notable that STS (7 = .03, р < .39) and ВО (r=.01, p=.98) did not significantly relate to placement disruptions. Additional analysis of STS in this sample was conducted to explore its relationship to the dependent variable. A subset of the sample had high STS scores above an established clinical cutoff associated with positive PTSD findings (STSS Total Scores of 46 or higher; N = 198; Sprang etal., 2022). STS was significantly correlated with placement disruptions in this group (r=.23, р < .001). Measures of STS impact on functioning and intensity of STS symptoms were available for a subset of the sample who participated in follow-up interviews (N = 181). STS impact on functioning did not significantly correlate with placement disruptions (7 =.08, p=.19), but intensity of distress had a significant, weak relationship with the dependent variable (r = .18, p = .02).

The correlational analyses supported the selection of factors to be entered into a multiple regression model to further explore relationships to placement disruption. This combination of the variables included foster parent type (basic, therapeutic, medically complex), foster parenting experience, practical support, child trauma exposure and ability to meet child's needs/sense of competence. When entered in combination, each factor significantly related to the dependent variable of placement disruption. The factors had positive relationships with the dependent variable except for practical support, which had the expected inverse relationship with placement disruption. It was notable that years of foster parenting experience had a positive relationship with placement disruption. The overall model was significant (Constant = 6.21, F = 59.54, р < .001) and accounted for 25.8% of the variance in the dependent variable. Table 2 displays the full results of this analysis.

Discussion

The results from this study highlight specific caregiver and trauma factors that significantly impact placement disruptions for youth in foster care. This was a uniquely large-data set of families in the foster care system, which provided a mechanism for examining issues encountered and potential factors related to placement disruptions in other settings. First, it was concerning that in this large group, over one third of caregivers had experienced at least one or two placement disruptions not related to successfully securing permanency or reunification for a child, suggesting this is a common issue facing foster families. Given the widespread nature of the issue and established impact on children and families indicated in prior research, it begs the question of why these events occur and how they can be prevented. Upon examination of this sample, the participating caregivers appeared to be an experienced, educated and supported group on average. Notable stressors included moderate to extensive ехроsure to the trauma of the child in their care and moderate symptoms of STS overall. Additionally, the caregivers reported that the severity of a child's needs, the disruptive impact on the family, and not feeling capable of managing the child's needs were the most common reasons of those queried for placement disruptions. These findings suggested that trauma factors and ability to manage a child's needs may be notable contributors to placement disruption even in a resourced and experienced group of caregivers. However, the bivariate analyses did not reveal a significant relationship between STS and placement disruption, only with the amount of trauma exposure caregivers reported experiencing.

Regarding the role of trauma factors, the finding that dose or intensity of exposure to child trauma was related to placement disruption is consistent with other literature. Across studies of populations affected by trauma, dose of exposure is often associated with a variety of poor outcomes (Kaysen et al., 2010; Regehr et al, 2004). This variable has not been specifically explored in other studies of placement disruption; however, research with child welfare and other helping professionals has found the amount or intensity of exposure to indirect trauma to significantly relate to turnover and intent to leave the profession (Aminihajibashi et al., 2022; Haight et al., 2017; Kim et al., 2023). It has been posited that placement disruption may be a manifestation of a similar phenomenon for foster parents in that they are attempting to leave an overwhelming helping role and avoid further exposure to child trauma and other distressing circumstances. This was exemplified in recent study by Dowdy-Hazlett and Clark (2024), who found that for certain subgroups of foster parents, particularly those who fit their Strained Foster Parent profile, higher levels of STS associated with turnover and placement disruption as a means of escaping foster parenting demands. In the present study, a small subgroup of caregivers with STS above the clinical threshold were reporting significantly more placement disruptions. These findings support the need for screening and intervention with foster parents experiencing higher levels of indirect trauma exposure or clinically significant STS.

Another interesting finding emerged in the bivariate analysis and remained consistent in the multivariate analysis regarding the role of foster parent experience in placement disruption. Among helping professionals and carers, years of experience is often thought to be a mitigating factor against distress and associated negative outcomes. However, experience has been found to serve as both a risk and protective factor for STS and has even functioned as a moderator in at least one study (Melinte etal.,2023; Moreno-Jimenez et al., 2020; Shoji et al, 2015). Experience appears to have a more complex role in contributing to the phenomenon of placement disruptions as well. The results from this study found that placement disruptions increased with years of foster parenting experience. It is possible that years of experience is serving as a proxy for time caring for children in foster care, the number of children, or even amount of indirect exposure to child trauma. While there may be a natural tendency to assume that the more experienced foster parents can unilaterally handle the most challenging placements without concern for disruption, these findings suggest otherwise. Further research is certainly needed to explore potential moderating or mediating effects of this variable, and additional supports for experienced foster parents with other risks for placement disruption may be indicated.

Further multivariate analysis was conducted to examine how certain combinations of factors may associate with placement disruption. In this sample, when caring for children with more special needs and experiencing greater secondary trauma exposure, in absence of sufficient support and a sense of competence, experienced foster parents were at increased risk for placement disruption. This strongly suggests the need to screen and support therapeutic or medically complex foster parents who have been exposed to considerable trauma, either from having numerous children placed in their care or involvement with high-risk cases such as injuries associated with near-fatalities or other severe impacts of maltreatment. This combination of factors accounted for over one quarter of the variance in the dependent variable and all factors remained significant in the model. This indicates several potential avenues for identification of foster parent needs and intervention-i.e., at foster parent certification, upon placement of new children into a home, when assessing the children's needs for trauma therapy, etc.

Implications

This study uncovered some important risk factors for placement disruption at the foster parent, child, and system level, suggesting that any response formulation should include a targeted, multi-pronged approach. Consistent with other studies, a child's experience with trauma presents specific challenges to foster parenting (Clark et al., 2020), namely problems managing externalizing and other problem behaviors (Chamberlin et al., 2006; Christiansen et al., 2010; Cloitre et al., 2009). Foster parents'sense of competence at managing trauma sequalae, especially in the context of therapeutic or medically fragile foster care provision, can be enhanced through trauma-informed parenting practices using curriculum such as Caring for Children Who Have Experienced Trauma: A Workshop for Resources Parents (Grillo et al., 2010). Studies demonstrate that resource parents (kinship and foster parents) completing this workshop showed improvements in their knowledge of trauma-informed parenting and perceived self-efficacy in providing care to a child who experienced trauma (Sullivan et al, 2016). These resource parents also showed decreases in parenting stress, a more positive emotional valence toward the children they were parenting, and increases in trauma-focused treatment provision for those in their care (Konjin et al., 2020). Early identification of children with traumatic stress symptoms-those severe enough to impact their functioning-through the use of universal trauma screening protocols could provide opportunities for matching children with traumainformed foster parents who have these enhanced skill sets. System-level interventions that incentivize the development and maintenance of trauma-responsive skill acquisition through leveling or credentialing practices, along with the provision of enhanced practical support could further reinforce this higher level of care. Previous research has identified the need for more advanced, specialized training opportunities (like trauma-informed parenting), creation of a foster parent support network, increased background information about the experiences of the child in their care, and self-care skills as important practical support measures (Kaasboll et al., 2019; Brown, 2007). Individual and system-led strategies to address secondary traumatic stress are especially important for those foster caregivers with symptoms in the high to extreme range, as this study indicates these placements are at increased risk of disruption.

Limitations

Despite the important implications of this data, a few limitations should be noted. The methodological approach utilized in this study required respondents to reflect on past emotional states and experiences, introducing the possibility of retrospective recall error. Furthermore, the self-report nature of their responses is limited by personal awareness and the response format, which required straightforward categorization of complex situations. Still, social desirability bias, a potential risk with self-report designs was likely minimized by the anonymous nature of the survey. The data presented here is a cross-sectional snapshot of the foster parent experience and could be enhanced by longitudinal study of factors impacting placement disruption over time as foster parents attempt to adjust to the challenges of parenting children with complex needs. Likewise, respondents were reporting on their experiences during the onset of a pandemic when resources and support were uniquely compromised, so results should be interpreted within that context. Finally, generalizability beyond this sample of self-selected, primarily Caucasian foster parents, though representative of the overall profile in the state, is limited. Future research with more diverse samples could provide more nuanced insights into the placement disruption challenges experienced by racial, ethnic and socially disadvantaged subgroups, especially those impacted by other socioenvironmental stressors (e.g., poverty, isolation, community violence) and in families affected by cross-racial or cultural dynamics. Also, examination of the role of these factors in kinship placements is needed to determine if similar patterns exist and what else may impact placement stability.

Conclusion

Placement disruptions in foster care present myriad costs to children who are emotionally vulnerable, families, and already under-resourced and strained systems. There are numerous factors that contribute to placement instability that offer opportunities for prevention and intervention. This study highlighted the specific interactions and challenges of caring for children with special needs and experiencing greater secondary trauma exposure, in absence of sufficient support and a sense of competence. Even experienced foster parents were at increased risk for placement disruption in these circumstances. The need for more trauma-informed training, interventions and supports to both children and caregivers in foster care appears warranted to help stabilize foster placements. Further research on this critical issue is needed to advance trauma-informed policies and practices in foster care.

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