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

Michael Tarren-Sweeney


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

In This Article

Risk, Prevention and the Therapeutic Potential of Alternate Care

Mental health and resilience among children in care are hypothesized to arise from complex, time-sensitive interactions between genotype, prenatal conditions, precare and in-care psychosocial conditions and events, and infant neurological development.[24] The social experiences that predicate entry into care represent critical developmental risks for their wellbeing and mental health. Foremost of these is exposure to psychological trauma, emotional deprivation, and other conditions that negate opportunity for secure attachments. Children in care also encounter a number of uncommon developmental events, the most critical being the loss of their biological parents, integration into new families or nonfamily settings, and (for some at least) unstable placements. Developmental psychopathology models pertaining to maltreated children[25] and profoundly deprived intercountry adoptees[26] are thus only partially valid for children in care, as there are both commonalities and differences in their experience.

Key predictors of mental health and wellbeing identified from risk studies of children in care include older age at entry into care, placement instability, perceived placement insecurity, and intellectual disability[10•,27] Younger age at entry into family-type (i.e. foster and kinship) care appears to be protective for subsequent mental health,[10•,28] while early placement in residential care is harmful.[29] These findings can be interpreted in terms of ‘cumulative adversity’ and ‘attachment’ models. Whereas a single harmful event may have life-altering developmental consequences for children at large, the impact of individual events is tempered among children exposed to chronic and multiple adversities.[30] For them, length and severity of exposure has greater impact than the types of harm encountered.[10•] Age at entry into care also has significance in terms of attachment quality, and related emotional and neurological development. It is known that emotional deprivation and abuse in early childhood may lead to development of disorganized or disordered attachments.[31•] Other precare experiences that affect attachment include the repeated loss of significant caregivers, and a pattern of serial caregiving by unfamiliar adults (such as temporary foster carers, or friends of birth parents). Attachment theory would predict that the therapeutic potential of alternate care should vary according to, first, the characteristics of children's attachment systems at entry into care and, second, carer sensitivity and ability to provide a ‘secure base’.[32,33] Regardless of prior conditions, the attachment systems of infants who enter foster care are found to be responsive to changes in parenting style.[34] Beyond infancy, there is evidence of linear deterioration in the mental health of children entering foster care at progressively older ages, including increasing interpersonal behaviour problems suggestive of attachment disturbances.[10•] The attachment difficulties of late-placed children are more resistant to therapeutic change in response to markedly improved care. This is partly due to them having more ‘established’ internal representations of self and others. One study found that birth maternal representations of late-placed children are shaped by the extent of maltreatment in their mothers’ care, and in turn influence their representations of their foster mothers, and their mental health.[35] Another risk encountered by late-placed children is placement instability.[10•] Placements typically break down when caregivers are confronted by severely disruptive behaviour. Placement instability accounts for further deterioration in children's mental health, over and above the difficulties children bring to their placements.[27,36] This contributes to the spiralling decline in stability and functioning observed among children who endure repeated placement breakdowns. Together these findings suggest that the therapeutic potential of foster and kinship care is greater for children placed at earlier ages,[10•] and conversely, that late placement of children with preexisting attachment and mental health difficulties may have limited therapeutic potential.[27]

One study found that indicators of placement security predicted better mental health among preadolescent children in care.[10•] Another study found that retrospectively measured perceived (i.e. ‘felt’) security was associated with positive outcomes for young adults after they left care.[37] The present author has hypothesized that children's insecurity and fear of loss and separation escalate over time via two related mechanisms: first, increased understanding of their birth and legal status, and the status of their carers (linked to their level of cognitive development); and second, as a response to their carers’ expressed insecurity.[10•] The findings provide tentative support for policies that promote permanency for children in long-term care.


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