The Mental Health of Children in Out-of-Home Care

Michael Tarren-Sweeney


Curr Opin Psychiatry. 2008;21(4):345-349. 

In This Article

Scale and Complexity of Mental Health Problems

Children residing in court-ordered care are collectively referred to as ‘looked after’ children in Britain and Ireland, and as children in ‘out-of-home care’ in North America and Australasia, although neither term satisfactorily describes the status of children in long-term alternate care. Although there is considerable variation in care systems, most Western jurisdictions shifted emphasis from nonfamily residential care to foster care through the late twentieth century, and more recently to kinship care. The latter trend is partly driven in Australia, New Zealand and Canada by concern for the identity and wellbeing of large and disproportionate numbers of indigenous children in care (see for example[1]).

More is known about the scale and severity of mental health problems manifested by children in care than of their nature, characteristics or underlying mechanisms. This is largely because most available estimates were obtained as outcome measures in studies addressing nonclinical research questions. Over 20 such studies in North America, Europe and Australia have measured psychopathology using standard caregiver-report rating scales, primarily the Child Behavior Checklist (CBCL)[2] and the Rutter Scales. These studies consistently found that children in care more closely resemble clinic-referred than normative samples, in terms of the scale of their mental health problems.[3,4,5,6,7,8] The distributions of CBCL ‘social problems’, ‘thought problems’, ‘attention problems’, ‘rule-breaking/delinquent behaviour’, and ‘aggressive behaviour’ scores approach those of clinic-referred groups.[2,6] Foster children are between three and four times more likely than children at large to have clinically significant CBCL total problem and externalizing scores, while the prevalence of internalizing problems is about 1.5-2 times higher. Around half of children in foster care score in the clinical range on one or more broadband or syndrome scales, while around three-quarters of children score above one or more borderline range cut-points.

Older age is associated with poorer mental health among children in care, as indicated by differences in age-standardized CBCL scores.[3,4,9] This apparent age effect, however, is confounded by age at entry into care. Older children are also more likely to have entered care at an older age and with poorer precare mental health.[10•] There are inconsistent data regarding gender differences in mental health.[6] Children in residential care have more mental health problems than those in family-type foster care[11] while those in kinship care have fewer problems.[12] Whether these differences are accounted for by different care experiences, or by selection effects, remains unclear.

Studies have estimated a high prevalence of DSM-III-R and DSM-IV conduct disorder (17-45%), attention-deficit hyperactivity disorder (10-30%), depression (4-36%), and generalised anxiety (or DSM-III-R overanxious) disorder (4-26%) among mixed samples of children and youth in foster and residential care.[13,14,15,16] The variability in estimated rates is probably more a consequence of differences in study design, than in the populations selected. Two studies estimated similar prevalence (40% and 50%) of post-traumatic stress disorder among maltreated children at time of entry into care, with a third of cases failing to resolve after 2 years in care.[17,18] In a national US survey of adolescent substance use, adolescents in care (n = 464) had much greater 12-month self-reported incidence of psychiatric symptoms than other youth (n = 18 966), including anxiety, mood and disruptive behaviour symptoms.[19] They also had higher incidence of substance-use disorders and attempted suicide.

What of other difficulties? Children in care endure poorer physical health, higher prevalence of learning and language difficulties, and inferior educational outcomes than other children.[20] Consistent with a background of complex maltreatment, up to a third of children in care present with problematic sexual behaviour that is possibly mediated by attachment difficulties.[21,22] In a recent survey that focused on under-researched psychopathology, large proportions of 4-year-old to 11-year-old children in foster and kinship care (n = 347) manifested interpersonal behaviour problems suggestive of disordered or disorganized attachments.[6] Sizeable proportions of this sample displayed self-injury, and abnormal responses to pain. A pattern of excessive eating and food maintenance behaviour without concurrent obesity was also identified, resembling the behavioural correlates of hyperphagic short stature (psychosocial dwarfism).[23]

In summary, children in care manifest complex psychopathology, characterized by attachment difficulties, relationship insecurity, sexual behaviour, trauma-related anxiety, conduct problems and defiance, and inattention/hyperactivity, as well as uncommon problems such as self-injury and food maintenance behaviours.


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