This article discusses the problems of medically fragile children, drug affected and/or HIV infected. Passage of the Adoption Assistance and Child Welfare Act of 1980 markedly increased the number of these children in foster care. The specific barriers to permanency planning for this group of children are discussed and include interviews with staff people, review of the literature and integration of material from pilot studies of families fostering and adopting children with HIV.The passage of P.L. 96-272, the Adoption Assistance and Child Welfare Act of 1980, established a national policy affecting permanency initiatives for children in the foster care system and those at risk of entrance into the Child Welfare System. The legislation emphasized, in order of preference, preservation of the family at risk of disintegration, reunification of children with the biological family if children are in out-of-home care, promotion of adoption if reunification cannot be achieved, guardianship, and long-term foster care. Child welfare service providers were legally mandated to provide effective and timely permanency planning of these options. The passage of this legislation had particular relevance for children with special needs. The