Kinship Foster Care – PediaCast 377

Show Notes


  • Dr David Rubin, founding co-director of the PolicyLab at The Children’s Hospital of Philadelphia (CHOP), visits the PediaCast Studio to talk about kinship foster care. Millions of children have spent time living with extended relatives. We’ll talk about the needs and challenges these families face, along with available resources and best practices for navigating systems. We hope you can join us!


  • Kinship Foster Care




Announcer 1: This is PediaCast.


Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.  

It is Episode 377 for May 31st, 2017. We're calling this one "Kinship Foster Care". I want to welcome everyone to the program.  

So, I mentioned a couple weeks ago that we've covered lots of topic in the ten-year life of this podcast. And in fact, we've covered many topics on more than one occasion, sometimes many occasions. For instance, asthma, things that are really common and yet sort of complicated and as the evidence changes and we learn more and gain more experience, there are new things to say about it.

And, of course, you guys have questions. And often, those questions shed new light, different perspective, may be some other context related to something we've covered before. So, that we can cover a little bit different angle, really put an emphasis on whatever it is that you need us to based on your question. So, we do cover things more than once.  

And, of course, as soon as I make that observation, here we are today with the fantastic topic that I don't think we've covered before. Maybe briefly with a passing mention and maybe not even that. And the topic is the foster care. 

Now, you may be thinking, "I don't take care of foster children. And my child is not in a foster home. So, should I care about this?" And the answer is absolutely yes. You should care and there are many reasons why that is.


First, the best foster homes, as we'll explore in today's episode, are kinship foster homes which amounts to kids living with relatives who are not their biological parent. And it's important that kids will remain with family when possible. And who knows, maybe someday you'll be that family member that maintains connections and supportive nurturing when mom and dad cannot.

And of course, there many reasons why that sort of situation might come up — chronic illness  or death of one or both biological parents, military deployment, incarceration, mental health disorders, substance abuse, all sorts of reasons. And we can't always predict when and how these sorts of things will come up. So, I think it's good to have a working knowledge and understanding of the concepts and challenges and barriers and the benefits surrounding kinship foster care. 

Second, foster care affects communities. As we'll soon discover, fostering children gets complicated in a hurry. Many many needs — legal, financial, medical, academic, social — lots to consider. And it's important that community resources are available and interacting and collaborating which does not happen on its own. Sometimes an advocate and that might be you needs to step up to the plate and make things happen in your community.

So, you can make a big difference in the lives of many families and kids by getting involved at the local level. And we'll talk more about this today as we consider the role of kinship navigator.

And third, I realized the target audience for this podcast is moms and dads but I also know we have lots of child health providers of one flavor or another who tune in. And many of you are teachers or social workers, policy makers. So, the consideration of kinship foster care, and foster care in general, is important to all of you maybe not in your role as a parent but in whatever other role you play in life.


And hopefully, we'll learn something new in our quest for best outcomes for the kids and our families and communities. 

Of course, in our usual PediaCast passion I have a fantastic guest this week, Dr. David Rubin
 will be joining as by phone.  He's the founding co-director of the PolicyLab at the Children's Hospital of Philadelphia, known in pediatric circles as CHOP. And he's also lead author of a new policy statement from the American Academy of Pediatrics called Needs of Kinship Care Families and Pediatric Practice.

So, stay tune as we get Dr. Rubin patched into the studio in just a few moments.  

First, though, I do want to remind you if there's a topic that you would like us to cover, if you have a question for me or you want to point me in the direction of a news article or journal article, easy to get in touch, just head over to and click on the Contact link. I do read each and every one of those that come through and we'll try to get your comments or your suggestion or you question on the program.   

Also, I want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement. You can find that at 

Let's take a quick break and I will be back, we'll talk more about kinship foster care. That's up coming up right after this.  



Dr. Mike Patrick: Dr. David Rubin is a professor of Pediatrics at the University of Pennsylvania Perelman School of Medicine and founding co-director of PolicyLab at the Children's Hospital of Philadelphia. Dr. Rubin recently served as lead author of the American Academy of Pediatrics policy statement called Needs of Kinship Care Families and Pediatric Practice, which was published in the March 2017 edition of the journal Pediatrics.

That's why he's here to talk about, kinship foster care. So let's give a warm PediaCast welcome to Dr. David Rubin. Thanks for joining us today.

Dr. David Rubin: Thank you.

Dr. Mike Patrick: Yeah, really appreciate you taking time and talking with us. Let's start with a just what is a PolicyLab at the CHOP?

Dr. David Rubin: A PolicyLab is a public policy center, research center, here at the Children's Hospital of Philadelphia. And we like to say that our mission is evidence to impact better care for children here at the Children's Hospital of Philadelphia because many of us are clinicians has informed this interdisciplinary model where we surrounded ourselves with folks from a variety of discipline and particularly folks in communications and public policy, to develop a research model that really emphasize early engagement with policymakers — folks who are developing programs for children. So that we can design more solution or added research that helps them sort of make smarter more evidence-informed decisions about types of program and policy that children need.

Dr. Mike Patrick: That's great because a lot of times, at least with the old system, we would do research and it would get published in a journal. And some practitioners would read those journals and maybe get some ideas, but things didn't move fast. But when we do it intentionally and really try to connect with policymakers and think about social media and digital communications techniques, really were able make to a bigger impact, right?

Dr. David Rubin: Exactly. I almost could have transplanted you back into our conversations when we were developing the center. We have the best conversations. 


Dr. Mike Patrick: All right, so let's talk about foster care. Most, I think Americans in our audience are going to know some general ideas about the foster care system. But we also have an international audience and maybe this is a new term for them. Tell us what is foster care and how many children here in the United States live in a foster home?


Dr. David Rubin: Yeah. Foster care is a living arrangement for children who have been removed from the care usually of their biologic caregivers because of concerns about abuse and neglect. And the way our system works here in America, if there's a suspicion for child abuse and neglect, a report is made to Child Protective Services. 

And the way they handle it and intake those request may differ by locality, but in general what the job of Child Protective Services is to rescue that kid very quickly and then make a determination of whether they need to provide services to the family and the child within their current home. Or, if need be, to check that child's safety, to remove that child and place him in the home of either a non-relative caregiver or a relative caregiver which we call kinship care.

Dr. Mike Patrick: Right.

Dr. David Rubin: And so, that's sort of a bird's eye view, a very quick tool of what foster care is here in America.

Dr. Mike Patrick: And how many kids are in the foster care system?

Dr. David Rubin: Oh, that is varied. Those numbers fluctuate. After the Adoption and Safe Families Act in the late 90's, there was a real push to get a kid adopted, kids who were languishing in foster care for a long time and kids who've spent a few years or many years moving from home to home. Because foster care children can be sometimes hard to kind of keep in the same home. And so, they have a lot of problems with placement disruption.


And they were languishing. And there was a real push after the late 90s to get kids adopted. And so, the number has dropped and they kind of made I think somewhere in the 400,000 range. But in recent years have been climbing again, I think somewhat as a result of increased reporting going on, increased sort of challenges around poverty, and child abuse and neglect related issues coming out as a result of that. 

And then also, some of the recent epidemics including a serious opioid epidemic here in United States. Now, I think our numbers are up above 600,000 again for children in foster care in United States.  

Dr. Mike Patrick: That's a lot of kids. What then is kinship foster care? How is that different to the just regular foster care?

Dr. David Rubin: Well, kinship foster care refers to those kids who were sort of a adjudicated or either court-involved sort of placement out of home from their biologic care givers into foster care. The kinship care in which the foster care system has identified a relative, offer grandparents or an aunt or an uncle, but sometimes it's a neighbor. 

The idea being someone who really knows the child and who's agreed to take on caregiver responsibilities and someone who is able to pass through the regulatory requirements to be licensed as a foster care home.

And so, people in general, there's been a big push. And I think our own center has been a part of demonstrating some of the evidence for this, of identifying available kin for children because there's often not enough non-relative foster caregivers who are qualified to raise these children.

And to a large degree, the children I believe has some higher level of attachment to folks that they know if they have to be removed and with this trauma of separation. Finding a relative who is active in their life can be very helpful to them.


Dr. Mike Patrick: And I would imagine that this would also extend beyond just sort of official placement from child welfare agencies, but there's probably a lot of undocumented kinship foster care that's going on as well.

Dr. David Rubin: Absolutely. In fact, most children in kinship care in the United States today are not known to the child welfare system. Most folks are raised entirely outside welfare system in this country by a grandparent or relative.

If you look at the numbers by 2013, about 10% of children in this country were being raised in a home in which the head of the household was not the biologic parent — or 7.8 million children. And then, there are at least 2.7 million children by that time who were actually being raised by their relatives in the absence of biologic parents. 

And if you do the math in terms of the proportion of kids and sort of licensed foster care homes or in kinship here, there's only a couple of hundred thousands of those kids. That means 10% of our kids being raised in kinship care in this country are actually sort of court-adjudicated to those homes. 

Most families, you see, when they have these stressors kind of figure it out on their own. Mom or dad may disappear because of substance abuse issue and grandma takes the kid in. That's sort of the story here.

Dr. Mike Patrick: What are some other reasons that this sort of setup might take place? I think there's probably a lot of family members who don't really think about kinship foster care until there's something, there's a crisis in maybe extended family and they find themselves in the position of being the best one to take care of the kids. But what are some of the reasons that that may happen?

Dr. David Rubin: Remember, kinship foster care to me means those that's real minority of family to have. The child welfare agency has reached out and identified the caregiver who is kin to the child, licenses that home as a foster care, and actually provides them some resources to help take care of that child. 


That is the main on these cases. I mean, in most of these situations, like I said, we have caregivers or relatives who step up within the family to take in a child when the family identify there's a risk. Sometimes, it's because the parents dies, right? Sometimes parents are incarcerated. Other times the parents go AWOL. They disappear, they're gone. Substance abuse, you name it. Mental health issues. 

There's a variety of reasons, but at the end of the day, what you have in these families — and being a pediatrician, I see this every day at my practice — there's often a couple, whether it's the grandma or it's an aunt or an uncle even, in a family that has a lot of psychosocial stressors and dysfunction, there's often one or two people in that family that everyone knows in the family, that's the go-to person who takes on everyone, who's kind of holding that family together by thread and needle. 

Dr. Mike Patrick: Yeah. You mentioned those who are sort of in the system and find placement, the child welfare agency is able to license them as a foster home and get them set up with resources. But the families that sort of do this on their own or it's really voluntary and aren't known to child welfare, they may have those same needs and yet not be connected with the resources.

Dr. David Rubin: Absolutely. I think that's one of the things our statement really wanted to recognize — that most families are not in the child welfare system. And I think to get to those details you have to understand why they're not in the child welfare system. Number one, I don't know may the family who were looking to be involved. They'll have someone watching on them, right? 

These families have their own stressors. And even with a terrific caregiver, they may be past issues in that family or people who got to stay with the family who they would've never been able  to get through the licensing procedures. Maybe because they live in poverty and they couldn't a guarantee a single room for the child in which they weren't other children. Or, they maybe someone who has a prior conviction in the past that would've disqualify them from being a foster parent. 


But yes, I think most families will do this on their own. They may go down to court, be told in hearing they can go down the court and get a legal guardian. And they have to kind of navigate on their own. But if you actually at the statistics, families in sort of what I call informal kinship care — that being kinship care that takes place outside the child welfare system — their caregivers tend to be older, in poorer health, higher rates of poverty, and don't have resources. They're just doing this. 

So, their needs in many ways are greater than those kinship families who are actually licensed by the system. Certainly greater than the folks who are non-relative foster caregivers in the system, right?

Dr. Mike Patrick: Yeah, absolutely. And I think then, it becomes important that pediatric providers really clearly understand the nature of a child's living arrangement when they're seeing them. So, sometimes you we walk in the room. We just assume, "Oh, that's mom." But you really do want to take the time to figure out what the relationship is so you can identify this families and maybe help them connect with resources they need.

Dr. David Rubin: Absolutely, knowing that 10% of our kids are living in these homes. We take for granted when a child comes into our practice or into our emergency department and we see an adult by their side, we just assume that they're mom or dad. And we can't make that assumption anymore. 

And part of really helping the family begins with asking, "Hi, how you doing? Who are you?"


Dr. Mike Patrick: Yes.

Dr. David Rubin: And we take that question for granted. 


Dr. Mike Patrick: Yeah, absolutely. As we think about kinship foster care and maybe families who haven't been connected with resources, what are some of the legal considerations that are important for these families that maybe the pediatric provider should be bringing up? And I mentioned our primary audience for these podcasts is parents, but although we do have a lot of providers who listen as well. 

But I think then also it's important if you are in this kind of situation and your provider is not asking who you are, it's probably a good idea to tell them who you are and let them know what the relationship is, so that they can help you, right?

Dr. David Rubin: Absolutely. I think if we're actually trying to impact our kids with overall wellbeing and not just simply ensuring that they have immunization, et cetera, right? I mean, understanding that a child is in particularly informal kinship, or even formal kinship care, can allow you to ask questions about guardianship. Families need to get guardianship that doesn't shell that health insurance. How are they getting their health insurance? 

What school-related issues are raised? I mean, kids who were in kinship care in general tend to have a higher rates of behavioral problems than other kids who are being raised at home. Well, that's not surprising because you know they already have a trauma, a child abuse, neglect in their lives. And they may have developmental needs and issue with school district that need to be addressed, whether or not the guardian is a legal guardian to act on behalf of that child within a school district. 

There's financial considerations, like we talked, about in terms of these children sometimes with the need for psychological services. And for that reason, in the last ten years, there's been a series of a couple different pieces of legislation that have tried to help support Kinship Navigator Programs that families can reach out to for guidance around the guardianship issues, for guidance around school-related issues, for guidance around mental health related issues, both for the children and for the caregivers.


Dr. Mike Patrick: Yeah. Really a lot of legal considerations in terms of guardianship — who gives permission to get the immunization, or even gives them permission to go on a field trip. 

How do families get connected with the resources they need to make sure that everything's buttoned up? You mentioned that the child welfare agencies, folks don't necessarily want to be connected them with them. But in some places, can those agencies still help families get connected with all those stuff without necessarily having a case worker and being formally involved?

Dr. David Rubin: Absolutely. I think it actually happens more than you would think. I think there are a lot of times that a report comes in, and they'd be screened out. What I mean by screened out is someone makes a report that they're concerned about supervision of the child that may be in poverty. Either it's screened out or someone goes to investigate. They decide there wasn't child abuse but there's risk to the child. 

We have tons of stories in which system will actually identify a caregiver and actually drop the kid off to grandma and never opened them up for services. So this sort of back door kinship care has been happening for a long time.

And so, I think that folks should not be afraid if they are grandparents taking care of a child to call their local child system for guidance. They're not looking to bring children into the system, but they often can be  a terrific resource to refer you to other agencies within your community that can help you in terms of obtaining legal guardianship, in terms of some of these other needs around health insurance, around mental health related issues, et cetera.

I think with the interest in Kinship Navigator Program in many communities, could be in our larger cities who have Navigator Programs, but actually have actual agencies who have specific expertise in the needs of kinship families. They're not just there for kids in the child welfare system. They're really intended for folks who are mostly not. 


I think as pediatricians in particular and our social workers that are in our practice, if we're fortunate enough to have social work, I think it's incumbent on us to have somewhat a level of knowledge of those programs and be able to refer our families to them.

Dr. Mike Patrick: Yeah. In communities where there isn't a formal Kinship Navigator Program but really it is just the child welfare agency is the primary connection to those resources, then it's a good idea for the provider, the pediatrician, to really explain to parents that the child welfare agency really does want to help them and not necessarily take things over. So the way that we present it and make the referral can make all the difference.

Dr. David Rubin: Absolutely. I think the best referral is one that comes to the individual parent or kinship parents themselves. They're just going and asking for help. 

Dr. Mike Patrick: Yeah.

Dr. David Rubin: And most people don't realize that our child welfare system, the bulk of the work is not for foster care itself to provide resources to families. Keep kids at home. And in this case, keeping kids with kinship family outside the system I think is okay. And I think most child welfare systems recognize that.

Dr. Mike Patrick:  You'd mention that there was kind of a push for adoption at one point in the past. And now, we're not seeing that quite as much. Is there a reason that a kinship, especially if it's a long term arrangement, are the reasons that they don't necessarily want to adopt? Are there advantages for adoption? How do you come up with the plan with regard to that?

Dr. David Rubin: I do want to suggest there has been a focus for adoption. I think there is. I think there's just a lot of pressure on kinship coming into the system right now. So, I think that adoption has greatly increased after the weight and the focus on there. I mean, maybe they've fallen back a bit. 

But I think in terms of how kinship families treat the issue of adoption, often legal guardianship is all they want. For these kinship caregivers, they often have a relationship, they have a relationship with both parties. So adoption is not necessarily the end all-be all for a lot of these families. Real guardianship may suffice, because the child may continue to have some relationship with the bio caregiver that's more supervised within the family. 


And so, there's just different motivation that go in to the adoption versus just legal guardianship process.

Dr. Mike Patrick: I could see that you can really start to have some complex conflict going on with the biological parents if you're trying to adopt, as opposed to just sort of taking care of kids and needing the legal authority to make some decisions for him.

Dr. David Rubin: Yes, because you're terminating parental rights and that can get kind of tricky if it's your sister.

Dr. Mike Patrick: Yeah, absolutely. Tell us about the Fostering Connections Act of 2008. What is that and how does it help foster families?

Dr. David Rubin: Well, I think in some ways it starts to really address some of the standards for kinship care and trying to relax some standards of families can have a greater access to their kids. It started to promote Kinship Navigator Programs. 

If I can remember it myself, actually we had an important  article that came out right before the Fostered Connections Act of 2008. It was passed at the very end of the first presidency. And we have a manuscript that came out that looked at the behavioral outcomes of kids in formal kinship care in the child welfare system versus non-relative foster care. 

And what we demonstrated was that within 18 months to 3 years, the behavioral outcomes were better. Kids were doing better in the aggregate, in kinship care, than they were doing in non-relative foster care. Now, that doesn't mean that non-relative foster caregivers are bad. This isn't the end. 

Certainly, there are terrific homes where foster parents are doing an amazing job. But in the aggregate, we perceived at least from the families who are reporting behavioral problems in their kids, that either the kid because of that attachment, there was some sort of resilient factor that was promoted when the kid was with a relative. 


Or terminally, that the certain caregiver who is rating the scope of the behavioral problems did not see the kid's behavior as much of a problem as let's say a non-relative foster care did. Whatever the reason, they were less likely to have placement disruptions. And that's what's really important to ensuring to me a healthy kid who has as healthy an outcome as you might want for these kids. 

And so, we took that data down to Washington. I actually brought with myself a psychologist who works for kinship families and a grandparent who was from my practice. And it was really an amazing moment for me in the power of the citizens to inform legislation. I remember the grandparent I brought with me have the opportunity to meet with the senior legislative staff in our US Congress who's working on the legislation. And that staffer was asking her specific questions about the ways in which she had been treated by the child welfare system that really inhibited her ability to get her ability to get her paternal grandson. 

And some of that feedback indeed up in the law in terms of identifying that sometimes the foster care standards really work against licensing kinship caregivers and trying to relax some of those standards and create some exceptions for kinship caregivers to identify that family-finding was priority. Meaning that you couldn't just look on mom's side of the family and not look on dad's side of the family. But you really had to demonstrate that you were doing family-finding and then helping promote access to Kinship Navigator Programs. 

So we were right there on the center of it and there was a grandparent that was right at the center of it. I was really proud to be a part of that team. 


Dr. Mike Patrick: Yeah, that is really great. So the Fostering Connections Act of 2008 really requires child welfare agencies to look for kin to place kids in, preferentially over non-relatives. 

Dr. David Rubin: It's to ensure that family finding is in place. Ultimately, the decision is safety were the child welfare system. They still have to ensure that the home is safe for the child. And this is the tricky part where you get into it. You can try to promote standards through a law like Fostered Connections. But at the end of the day, these decisions are made on a one-by-one basis and there's a lot grey. 

But the important part that folks recognize is that they weren't doing a good enough job of identifying kinship resources in terms of they were not reaching out well enough. And if you're not reaching out well enough, then you're not even making that comparison really, that assessment, because you didn't bother to take the time to figure out who were the kin in the child's life. 

Once you get to the decision of safety, that's where it got into tricky though, those people out there that believe that the apple doesn't fall far from the tree. And certainly, we see in families where there's been child abuse and neglect that, at least those in the in child welfare system, that looked at that individual's problem, there's usually other issues throughout that family and other challenges that family's facing. Every family in this country has its own set of challenges, right? 

And so, folks would worry about, well, if we put the child in this house, would that birth parent have access to that child more than we would want? Would some of these issues related to substance abuse, well, there other members have issues with substance abuse in this house. And that's sort of apple fruit doesn't fall far from the tree. 

And then, there's this other camp that I think my data and some of the data of other sources I've sort of subscribed to, which is yeah, we understand these families may not be perfect but blood is thicker than water. And that means that some ways, this is my relatives, this is my family. And I'm going to look out for these kids. I may not be the perfect dad but I'm going to stick by this kid, right? 


And that's been my experience and practice. And I think that's it's been borne by some of the data on sort of how infrequently kids move in kinship care. 
Dr. Mike Patrick: Yeah. It really takes a special person in the child welfare agency to sort through all that, to figure out what really is in the best interest of the kid. And yeah, "We're going to do our best to find kin and sort of evaluate what that living situation would be like. But at the end of the day, we have to take all factors into account." 

And I love the fact that the grandparent was able to be involved and be asked, "Hey, what kind of hardships did you come across?" And you'd mention that maybe relax some of the licensing criteria. 

What are some examples of that? What are some safety things that you could relax a little bit in a kinship home that seems like it would be worth relaxing? 

Dr. David Rubin: Well, see, this is my own personal opinion, but some of the laws around guaranteeing that the child had a bedroom to themselves. If you understand a lot of kids have families are living in poverty, there might be other kids in the room and we may need to say that's okay. 

Dr. Mike Patrick: Yeah. 

Dr. David Rubin: I have this sort of belief, when you have, say, 35 or 45-year-old caregiver who had a felony conviction when they were in their 20s or drug-related arrest back in their 20s, should that disqualify them from being a kinship caregivers in their 40s? And I think that if we know anything about adult maturation, it's that who you are in your 20s is not necessarily who you are in your 30s or your 40s. 


And I think we need to be willing to take the chance when we're in those gray areas to honor the data and to take that chance and identify the strengths within that family and work with their strengths. Because at the end of the day, these are sort of very subjective decisions. You'd like to think you'd get more that life, and you're wrong. 

And the way I used to think about it is, you have a child — and we're talking with the kid in the child welfare system, not the ones that are being handled informally within their families — but you got a situation where you don't have enough non-relative foster care parents. And then, you have kinship parents. So what you want to do is get as many kids into get kinship setting who were appropriate for those settings and they have a relationship with the child. 

It's not okay just to say "Hey, I found a kin. They have no relationship with the child. I don't care about the child." It's got to be someone who have an investment in the kid. Even if it's a neighbor, I'll become happy with that. 

But the problem that you get into, the truly tragic stories to me are when you have let's say an infant who got placed into foster care with a really terrific foster care parent, non-relative. And that foster care parent wants to adopt them, and has had that child since birth. And at 18 months to 2 years of age, the court realizes that there's been a kinship caregiver who has been fighting for that child, to get custody of that child for a year and half, two years, and then — after two years of attachment with that foster parent — suddenly orders that kid to be return to a kinship caregiver. That is a tragic failure of our child welfare system when that occurs. 

So I'll tell you why. You had a terrific foster care parent who would have adopted the child and had done a terrific job with that child. And yet, you gave him a child who had a kinship alternative, didn't do the family-finding well enough at that time. You've now discouraged them from ever wanting to take another child into their home as a foster care child, because to meet with the family like that, it's really tragic for them. 


At the same time, you have a kinship caregiver who has a kid but wasn't allowed to really be a part of that child's life during his critical period of adjustment. So you feel tragic for them. And then, I feel tragic, what's tragic is that kid who's been languishing in foster care homes, from one home to the next, who really could have benefited from that foster care parent. 

Because we have to make sure, so again, in these subjective areas that we get the right kids into non-relative foster care homes who really don't have any alternatives. They're unfortunate, they don't even have kinship alternatives. And when we make a poor decision to place a child into foster care without having done our family-finding appropriately, there are number of people that trickle down really impacts negatively. And those are truly tragic cases.

So, when I say I hope the data on the kinship care sort of involving our child welfare workforce to really take that issue seriously and ensure that they do the best job of funding these cases. So they can make the smartest decision possible, knowing that there will be wins and losses. I mean, there will continue to be hits and misses, but if they do their work upfront and really invest in trying to do that.

 I will say that sometimes that involves the pediatrician because if one of my kids in practice gets reported, I like to be involved because I often know who their kinship caregivers are because they've often come with the kids to the appointment. So I can say, "Could you check out so and so?" "Did you check out so and so?" And so, sometimes that actually introduce the child welfare workers to someone who can help them solve this very quickly. 


Dr. Mike Patrick: The role of the kinship navigator, we've mentioned that a few times. What exactly is a kinship navigator? 

Dr. David Rubin: Well, I just think of it as a resource agency where people, it's the best source of information in the community for how to get  legal guardianship done, school district related issues, health insurance, sort of mental health resources. It's like one-stop shopping for the kinship families. Often, these are child service agencies that also may have other contracts for foster care or other stuff, but they just have specialization in kinship care. 

Dr. Mike Patrick: And if there's a community let's say that doesn't have a program like that in place and someone who was interested in putting something together, is that something they'd go to their congressman who would know where funding could come from? I mean, how, let's say in a medium-sized city and there just isn't something like that, how would you get something started? 

Dr. David Rubin: You're probably surpassing my knowledge for that. There's so much available over the Internet these days, that I would start by hitting Google and typing "kinship navigation programs" and calling a sample. So one of the benefits of our Internet sort of age that we're in is that you can get a lot of information very quickly. 

And so, if you're living in a rural community, if you're living in a smaller city, look up some of these kinship programs, call some of these larger programs. They're readily available on the Internet and they can start to help connect the dots for you and start to help you think about a community response to this issue. 

Dr. Mike Patrick: Now, you had mentioned that some of the data that sort of informed pushing for this legislation to begin with was the fact that there were advantages to kids who were in kinship foster care. What were some of those advantages that you found? Because it really went  beyond just behavioral stuff, right? I mean, even physical health. 


Dr. David Rubin: Well, I didn't get so much into physical health, but I think the biggest part for me is both the perception of behavioral problems, but also the stability of the children. The number one thing you can do for a child that's removed their home is to stabilize them as quickly as possible with someone who's going to take care of them, if need be, if they're not going to be reunited, who's going to really commit to them and stay with them. 

And the tremendous advantage of kinship care and the aggregate to doing that are huge advantage to trying to point that kid's sort of wellbeing in the north direction. Because you're trying to make up ground. There may be developmental delay in that child. There may be a lot of trauma and disruptive behavioral issues as the child is reacting to that trauma of separation. 

And so, to me that's the number thing. And from placement stability, from that stability in the home, everything comes from there, whether it's physical health, your mental, et cetera. 

Dr. Mike Patrick: Yeah, just kids and foster care in general, so we're not necessarily saying kinship foster care but just foster kids in general compared to those living with their biological parents, they do face a lot of challenges including physical health issues. 

Dr. David Rubin: Absolutely. Yeah, there's also the acknowledgement that kids who have had a lot of trauma in their lives — and you're talking about not just the trauma of separation but whatever was the source of their child abuse and neglect or victimization — there's a psychological manifestation for that. There's a long-term consequences of psychological manifestation including adult health issues, physical health issues. 

But there's also now recognition that sort of that trauma that children are exposed to, actually there's a connection between that and physical manifestations even in the young child. And the science of that has really been emerging in terms of its impacts on sort of a lot of hormonal axis within our body. 


I mean, kids in foster care are known to have much higher rate of asthma, for example, than other children in the same community, not explained by their physical living conditions. In fact, a lot of kids in foster care should be living in better living conditions than kids in the community, but the rates of asthma are higher. 

And as they get older, it's just suspected that some of the alterations in the inflammatory response in their own body in relationship to their trauma has probably gave them this higher rates of asthma. So there are lot of physical manifestations that can come just from the trauma itself. 

Dr. Mike Patrick: Yeah, and we're talking about toxic stress and this idea of resiliency then too. And I just want to put a plug-in because over on our CME podcast, over at PediaCast, we just did a Category 1 activity that folks can listen to and participate in that talks all about toxic stress and resiliency and how adverse childhood events can then lead to all sorts of mental health and physical health manifestations, not just in the immediate period but on down the road including into adulthood. 

And we had a great discussion with that with behavioral health specialists and psychologists and school-based folks. So I would encourage folks who were interested in learning more about what you're talking about with toxic stress and then combating that with resiliency. 

I'd encourage folks to head over to It was Episode 26 and they can listen to a great discussion on that. Let's talk a little about the role of the pediatrician in supporting these families. We mentioned it's really important to understand what the relationships are of the people in the room. But what is the role of the pediatrician in helping these kids?

Dr. David Rubin: We said in the beginning of our session together, first is ask the question, "Who are you?" "Hi, how are you doing? Tell me a little bit about you? Tell me where you're…" I always ask all my parents. When I get to meet them certainly early on, I ask them, "I'd like to know a little bit about your background." 


And through that conversation, you can figure out the relationships in the room. And once you identify them, you start asking questions, like "Do you have guardianship?" "Has that been a problem?" If the biologic parent's still involved, "How do you navigate that with the child? What sort of challenges are you facing?" "Do you have problems paying health insurance coverage?" "Have you had problems dealing with the school district?" "Have you made contact?" "Do you need mental health resources for yourself or your child?" "Financially, how are you doing?" 

And so, you're really doing a needs and assets kind of assessment. It doesn't take very long to do. And, I find sort of curiously really receptive, the doctor asked. And when I'm meeting with my own students or other pediatric trainees, I always say to them it's like if you peel back the onion, your ability to impact that family and help that family over time is so much greater. Because whether you need to involve a social worker to help them or really kind of identify kinship resource for them, you're going to help stabilize that child. And to me, I feel every time I walk out one of those rooms, I'm making a significant contributions towards pointing them in the right direction. 

Dr. Mike Patrick: Yeah. And part of pointing them in the right direction is knowing what your local community resources are and educating yourself on the state and local laws surrounding consent and health coverage and kinship care. 

Dr. David Rubin: Exactly. 

Dr. Mike Patrick: The American Academy of Pediatrics does have some great resources for helping develop a plan of action for all foster kids whether it's kinship care or not. I'm going to put some links in the Show Notes for this episode, 377, over at But the AAP has a Healthy Foster Care America landing site. 

And then, there's also a digital book that's available on fostering health, which really is just a practice toolkit for helping providers really support foster families, whether it's non-relatives or kinship care. 


And since we're talking to a lot of parents out there, if you are a part of the foster care system or you know someone who is, you may want to tell your pediatrician or family doctor, whoever it is that takes care of your kids about these resources. So that they can be most knowledgeable not only for helping you, but for helping all the other families in their practice as well. 

Dr. David Rubin: Yeah, that sounds great. It's been terrific talking to you about this. I'm a big fan of kinship families. I love seeing my kids and families in my practices and I think that our ability to help is a lot more significant than most pediatricians really understand. I think they really appreciate it. 

And I actually think that over the last ten years, we've seen a dramatic surge in the number of families in which kids are being raised by grandparents or aunts and uncles.  So I think it's really our responsibility. 

Dr. Mike Patrick: In addition to just dealing with the families themselves, what sort of advocacy opportunity exists for folks who are interested in terms of really informing public policy?

Dr. David Rubin: I think particularly in the vicinity of the state level, tremendous amounts. I mean, I think that I would touch base with your own Kinship Navigator Programs to verify those opportunities. And like you said, those numbers, I think you'll find as you start to reach out that when I'm quoting 10% that means 10% of even your legislators and the folks we meet. Well, everyone has a story about grandma or an aunt and uncle, which are important in their lives. And it crosses both parties. 

So this is a bipartisan issue, supporting families who are stepping up to the plate here. And so, it's really a tremendous opportunity. Even in the politicized world that we live in, you will find a lot of folks interested to talk about the needs of these families. 

Dr. Mike Patrick: A lot of folks have medical trainees in their office at some point. I think it's important to talk about it with them as well, because you may be the only person who does so. 


Dr. David Rubin: Absolutely. Absolutely. I think that this idea of really understanding the composition of the American family is a responsibility that we need to hold to our medical curriculum, for sure. 

Dr. Mike Patrick: Yeah, absolutely. We really appreciate you taking time and talking to us today. We're going to have lots of links in the Show Notes for folks. 

We mentioned you were the lead author of the recent American Academy of Pediatric policy statement, Needs of Kinship Care Families and Pediatric Practice. We'll put a link to that in the Show Notes, so folks can read it in its entirety if you're interested.

Also links to Healthy Foster Care America at the landing site of the American Academy of Pediatrics with lots of great resources for taking care of foster families. Also, a digital book called Fostering Health, also from the AAP, I'll put a link to that. 

And, of course, PolicyLab at the Children's Hospital of Philadelphia, also known as CHOP. And also your Twitter feed as well, so folks can follow you there. 

So, Dr. David Rubin, founding co-director of PolicyLab at the Children's Hospital of Philadelphia, thanks so much for stopping by today. 

Dr. David Rubin: Yeah, I also want to say thank you, guys. And also, I encourage other folks if they're interested, come visit us at or follow us on Twitter. Lots of great resources for folks. And it's been a pleasure doing the show. 



Dr. Mike Patrick: We are back with just enough time to say thanks to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that as always.

Also, thanks to our guest, Dr. David Rubin, founding co-director of Policy Lab at the Children's Hospital of Philadelphia. Really appreciate him taking time in educating time in educating all of us on the ins and outs of kinship foster care. Hopefully, you learned something new today. I sure did. 

Don't forget, you can find us in all sorts of places. We're in iTunes, Google Play, iHeart Radio, Stitcher, TuneIn, and most mobile podcasting apps.

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We also have a podcast for them, for pediatric providers, called PediaCast CME. That stands for Continuing Medical Education. It's similar to this program, we do turn the science up a couple of notches and offer free Category 1 Continuing Medical Education credit for those who participate. Shows and details are available at the landing site for that program, which is 


Thanks again for stopping by, and until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody. 


Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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